Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 036138972 | IL |
N | 111NI0900X | Internist | 036138972 | IL |
Y | 207RI0011X | Interventional Cardiology | 2021022845 | MO |
NPI | 1114369170 |
---|---|
Provider Name | Imtiaz Ismail |
First Address | Hannibal, MO 63401-6877 |
Second Address | Elmhurst, IL 60126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2013 |
Last Update Date | 13/07/2021 |