1124021829 NPI number — DR. BASSEM I RAZZOUK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124021829 NPI number — DR. BASSEM I RAZZOUK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

RAZZOUK

Provider First Name:

BASSEM

Provider Middle Name:

I

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1124021829

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/11/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

10330 N MERIDIAN ST

Provider Second Line Business Mailing Address:

SUITE 201

Provider Business Mailing Address City Name:

INDIANAPOLIS

Provider Business Mailing Address State Name:

IN

Provider Business Mailing Address Postal Code:

46290-1024

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

2001 W 86TH ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

INDIANAPOLIS

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

46260-1902

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

317-338-4673

Provider Business Practice Location Address Fax Number:

317-338-3227

Provider Enumeration Date:

05/27/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2080P0207X , with the licence number:  01063092A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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