1053310409 NPI number — MOHAMMED KAZIMUDDIN MD FACC FSCAI

Table of content: MOHAMMED KAZIMUDDIN MD FACC FSCAI (NPI 1053310409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053310409 NPI number — MOHAMMED KAZIMUDDIN MD FACC FSCAI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAZIMUDDIN
Provider First Name:
MOHAMMED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD FACC FSCAI
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:
1053310409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 SECOND AVE
Provider Second Line Business Mailing Address:
STE B1
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-782-0151
Provider Business Mailing Address Fax Number:
270-782-7528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 SECOND AVE
Provider Second Line Business Practice Location Address:
STE B1
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-782-0151
Provider Business Practice Location Address Fax Number:
270-782-7528
Provider Enumeration Date:
07/19/2005

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: 207RI0011X , with the licence number:  36951 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64044613 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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