1841366267 NPI number — DR. BASSAM M FAKHOURI M.D.

Table of content: DR. BASSAM M FAKHOURI M.D. (NPI 1841366267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841366267 NPI number — DR. BASSAM M FAKHOURI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAKHOURI
Provider First Name:
BASSAM
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAKHOURI
Provider Other First Name:
BASSAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841366267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8327 W PONTIAC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85382-1414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-825-2769
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4175 S ALAMO AVE
Provider Second Line Business Practice Location Address:
DAVIS-MONTHAN AFB
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85707-6097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-228-2600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  27732 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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