1083847321 NPI number — BASSIMA MOWAFFAK AL-DELAIGAN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083847321 NPI number — BASSIMA MOWAFFAK AL-DELAIGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AL-DELAIGAN
Provider First Name:
BASSIMA
Provider Middle Name:
MOWAFFAK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1083847321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 CRAMER CIR
Provider Second Line Business Mailing Address:
PENNOCK 502
Provider Business Mailing Address City Name:
BIG RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49307-2736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-591-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 CRAMER CIR
Provider Second Line Business Practice Location Address:
PENNOCK 502
Provider Business Practice Location Address City Name:
BIG RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49307-2736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-591-2222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2009

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: 152W00000X , with the licence number:  4901004547 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0784610001 . This is a "ADMINASTAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 999998001 . This is a "VSP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 900006367 . This is a "PRIORITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 900E47602 . This is a "BLUE CROSS MEDICAL" identifier . This identifiers is of the category "OTHER".




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