1063407534 NPI number — MOHAMMAD A ALSOUB MD

Table of content: MOHAMMAD A ALSOUB MD (NPI 1063407534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063407534 NPI number — MOHAMMAD A ALSOUB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALSOUB
Provider First Name:
MOHAMMAD
Provider Middle Name:
A
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:
1063407534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 CRESTVIEW PARK DR STE 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DICKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37055-2856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-446-5121
Provider Business Mailing Address Fax Number:
615-446-1359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 HIGHWAY 70 E STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DICKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37055-2080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-375-1531
Provider Business Practice Location Address Fax Number:
615-375-1526
Provider Enumeration Date:
09/12/2005

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: 207RC0200X , with the licence number:  38437 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 38437 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4138005 . This is a "BLUE CROSS BLUE SHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 103I295563 . This is a "MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3894698 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6060612 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00359629 . This is a "RAILROAD MEDICARE PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1516719 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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