1861801029 NPI number — ISSAM ALBANNA, MD, PA

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 1861801029 NPI number — ISSAM ALBANNA, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISSAM ALBANNA, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1861801029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3288 COVE BEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33613-2752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-979-4435
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3288 COVE BEND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-2752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-979-4435
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ALBANNA
Authorized Official First Name:
ISSAM
Authorized Official Middle Name:
I
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
813-979-4435

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME0061731 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 379455500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118493200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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