1851393839 NPI number — NISSIM KHABIE M.D.

Table of content: NISSIM KHABIE M.D. (NPI 1851393839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851393839 NPI number — NISSIM KHABIE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHABIE
Provider First Name:
NISSIM
Provider Middle Name:
Provider Name Prefix Text:
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:
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:
1851393839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-871-1144
Provider Business Mailing Address Fax Number:
612-871-2012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-871-1144
Provider Business Practice Location Address Fax Number:
612-871-2012
Provider Enumeration Date:
08/10/2005

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: 207Y00000X , with the licence number:  42203 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34190100 . This is a "MEDICAID - WISCONSIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1000350 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1000010 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1592346 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01031020 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 141063 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 951427900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 055M7KH . This is a "BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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