Basic Information
| Provider Information | |||||||||
| NPI: | 1962479998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QURESHI | ||||||||
| FirstName: | AZRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE | ||||||||
| Address2: | 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152542630 | ||||||||
| FaxNumber: | 2157539447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1602-04 WADSWORTH AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157539438 | ||||||||
| FaxNumber: | 2157539447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD060880L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0016169100005 | 05 | PA | MEDICAID |