Basic Information
Provider Information | |||||||||
NPI: | 1356537179 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REZ | ||||||||
FirstName: | AHMAD | ||||||||
MiddleName: | OSAMA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12101 WOODCREST EXECUTIVE DR | ||||||||
Address2: | SUITE 210 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631415047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143170600 | ||||||||
FaxNumber: | 3143170606 | ||||||||
Practice Location | |||||||||
Address1: | 1 SAINT ANTHONYS WAY | ||||||||
Address2: |   | ||||||||
City: | ALTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620024568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143170600 | ||||||||
FaxNumber: | 3143170606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2007 | ||||||||
LastUpdateDate: | 10/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036.131216 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 2010014085 | MO | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 036.131216 | IL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.