1659991891 NPI number — MR. ISAAC ALGHOOSEN AA

Table of content: MR. ISAAC ALGHOOSEN AA (NPI 1659991891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659991891 NPI number — MR. ISAAC ALGHOOSEN AA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALGHOOSEN
Provider First Name:
ISAAC
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AA
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:
1659991891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 W FOREST HOME AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-389-2377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 W OKLAHOMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215-4330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-649-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2020

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: 367H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100100762 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".