1699165209 NPI number — MOHAMMED BOUSOFA CRNA

Table of content: MOHAMMED BOUSOFA CRNA (NPI 1699165209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699165209 NPI number — MOHAMMED BOUSOFA CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUSOFA
Provider First Name:
MOHAMMED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1699165209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-0865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-715-5000
Provider Business Mailing Address Fax Number:
972-715-9976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 CITYWEST BLVD
Provider Second Line Business Practice Location Address:
STE. 300
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-620-4000
Provider Business Practice Location Address Fax Number:
713-458-4229
Provider Enumeration Date:
02/03/2015

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: 367500000X , with the licence number:  187091 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP127291 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: RR MEDICARE . This is a "P01540692" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8157UK . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 345516401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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