1992764674 NPI number — MOUSHIRA A EBRAHIM

Table of content: (NPI 1992764674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992764674 NPI number — MOUSHIRA A EBRAHIM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUSHIRA A EBRAHIM
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:
1992764674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1888
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75403-1888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-455-4051
Provider Business Mailing Address Fax Number:
903-454-1716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4818 WELLINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75402-6010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-455-4051
Provider Business Practice Location Address Fax Number:
903-455-4051
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EBRAHIM
Authorized Official First Name:
MOUSHIRA
Authorized Official Middle Name:
ANWAR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-454-4051

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 094948902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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