1144726084 NPI number — NIMROD SHABTAI BARASHI GOZAL MD

Table of content: NIMROD SHABTAI BARASHI GOZAL MD (NPI 1144726084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144726084 NPI number — NIMROD SHABTAI BARASHI GOZAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARASHI GOZAL
Provider First Name:
NIMROD
Provider Middle Name:
SHABTAI
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:
1144726084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 E OHIO ST APT 1703
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-4685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-989-5017
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 SAINT LUKES CENTER DR STE 24B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017-3509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-685-7830
Provider Business Practice Location Address Fax Number:
314-590-5971
Provider Enumeration Date:
03/31/2018

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: 208800000X , with the licence number:  2024000198 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200094624 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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