1295714129 NPI number — DR. AZZAM A ADHAL MD

Table of content: DR. AZZAM A ADHAL MD (NPI 1295714129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295714129 NPI number — DR. AZZAM A ADHAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADHAL
Provider First Name:
AZZAM
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
1295714129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32406-5909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-784-6696
Provider Business Mailing Address Fax Number:
850-785-2100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2195 JENKS AVE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-784-6696
Provider Business Practice Location Address Fax Number:
850-785-2100
Provider Enumeration Date:
01/10/2006

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:  ME39261 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 066935100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0080N . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1518360288 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 066935100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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