1639149131 NPI number — DR. ABDELKARIM WANESS MD

Table of content: DR. ABDELKARIM WANESS MD (NPI 1639149131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639149131 NPI number — DR. ABDELKARIM WANESS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANESS
Provider First Name:
ABDELKARIM
Provider Middle Name:
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:
1639149131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 MOORE RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44011-4044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-930-4446
Provider Business Mailing Address Fax Number:
440-934-0682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10325 DEWHURST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELYRIA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44035-8403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-366-3600
Provider Business Practice Location Address Fax Number:
440-365-8826
Provider Enumeration Date:
01/25/2006

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:  35066110 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000128702 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: E66110 . This is a "SUMMA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0979508 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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