1235121237 NPI number — FAHEEM B NUSRAT MD

Table of content: FAHEEM B NUSRAT MD (NPI 1235121237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235121237 NPI number — FAHEEM B NUSRAT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUSRAT
Provider First Name:
FAHEEM
Provider Middle Name:
B
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:
1235121237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UNIVERSITY MEDICAL GROUP
Provider Second Line Business Mailing Address:
P O BOX 1705
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30903-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-774-7261
Provider Business Mailing Address Fax Number:
706-774-7279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 SILVER BLUFF RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-648-0587
Provider Business Practice Location Address Fax Number:
803-648-9846
Provider Enumeration Date:
08/17/2005

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: 207R00000X , with the licence number:  044043 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD38409 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000788081E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111811 . This is a "MEDICARE FQHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 342410 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 11SCCWT . This is a "MEDICARE FFS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 341629 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GRP1619 . This is a "MEDICARE FFS GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000788081B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10057307 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 341628 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000471809A . This is a "MEDICAID FQHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000471809B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 341630 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00015170 . This is a "MEDICARE RR RETIRED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111812 . This is a "MEDICARE FQHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 111814 . This is a "MEDICARE FQHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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