1508957200 NPI number — EMAD ROSHDY BASSALY MD

Table of content: EMAD ROSHDY BASSALY MD (NPI 1508957200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508957200 NPI number — EMAD ROSHDY BASSALY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASSALY
Provider First Name:
EMAD
Provider Middle Name:
ROSHDY
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:
BASSALY
Provider Other First Name:
EMAD
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508957200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 CHURCH POND DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIVERTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-624-1997
Provider Business Mailing Address Fax Number:
401-624-7920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 MENDON RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02864-4337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-333-6100
Provider Business Practice Location Address Fax Number:
401-333-6109
Provider Enumeration Date:
09/27/2006

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: 207LP2900X , with the licence number:  MD10521 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 46332 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0138967 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110003241A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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