1043286453 NPI number — IMAD I NASSIF MD

Table of content: IMAD I NASSIF MD (NPI 1043286453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043286453 NPI number — IMAD I NASSIF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NASSIF
Provider First Name:
IMAD
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1043286453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9050 E 29TH ST N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67226-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-219-9651
Provider Business Mailing Address Fax Number:
316-219-9655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9050 E 29TH ST N
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-219-9651
Provider Business Practice Location Address Fax Number:
316-219-9655
Provider Enumeration Date:
02/24/2006

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: 207R00000X , with the licence number:  0428527 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102935 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1003616808 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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