1053550897 NPI number — HOSPITALIST ASSOCIATE TEAM

Table of content: (NPI 1053550897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053550897 NPI number — HOSPITALIST ASSOCIATE TEAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOSPITALIST ASSOCIATE TEAM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053550897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40252-0787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-567-1506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5107 CRAIGS CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-4863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-393-3124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ADDAS
Authorized Official First Name:
MOUHAMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
859-393-3124

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9062366 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000620979 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 103431500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".