1982687521 NPI number — DR. BASMAN ABDEL SALOUS M.D.

Table of content: DR. BASMAN ABDEL SALOUS M.D. (NPI 1982687521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982687521 NPI number — DR. BASMAN ABDEL SALOUS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALOUS
Provider First Name:
BASMAN
Provider Middle Name:
ABDEL
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:
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:
1982687521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6913 N MAIN ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530-8039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-1500
Provider Business Practice Location Address Fax Number:
574-243-4310
Provider Enumeration Date:
11/29/2005

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: 207Q00000X , with the licence number:  01043104A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000085201 . This is a "BCBS BMG MAIN STREET" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000085202 . This is a "BCBS BMG IRELAND RD MED POINT" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000195021 . This is a "BCBS BMG E BLAIR WARNER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200042370 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000314664 . This is a "BCBS BMG IRELAND RD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000111141 . This is a "BCBS BMG PORTAGE RD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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