1053621060 NPI number — MASOUD KHORSAND-SAHBAIE, MD PA

Table of content: (NPI 1053621060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053621060 NPI number — MASOUD KHORSAND-SAHBAIE, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASOUD KHORSAND-SAHBAIE, 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:
1053621060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1574
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202-1574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-627-9505
Provider Business Mailing Address Fax Number:
877-749-7764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3028 N. GRIMES
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBBS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-392-0222
Provider Business Practice Location Address Fax Number:
575-392-0200
Provider Enumeration Date:
10/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COTTRELL
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS SYSTEMS/CREDENTIALING MGR
Authorized Official Telephone Number:
575-627-9508

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  96299 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: MD2012-0091 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z2565 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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