1114908639 NPI number — RIAD I HOMSI MD

Table of content: RIAD I HOMSI MD (NPI 1114908639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114908639 NPI number — RIAD I HOMSI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOMSI
Provider First Name:
RIAD
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:
1114908639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1798, DEPT 07-044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-9715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-507-8675
Provider Business Mailing Address Fax Number:
901-507-8696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6373 N QUAIL HOLLOW RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-3812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-507-8675
Provider Business Practice Location Address Fax Number:
901-507-8696
Provider Enumeration Date:
11/10/2005

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: 207V00000X , with the licence number:  MD25479 , 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: 3728303 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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