1932187044 NPI number — MASOUD KHORSAND- SAHBAIE MD P A

Table of content: (NPI 1932187044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932187044 NPI number — MASOUD KHORSAND- SAHBAIE MD P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASOUD KHORSAND- SAHBAIE MD P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1932187044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1574
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202-1574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-627-9508
Provider Business Mailing Address Fax Number:
877-749-7764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MILITARY HEIGHTS PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-6407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-627-9500
Provider Business Practice Location Address Fax Number:
877-749-7764
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KHORSAND-SAHBAIE
Authorized Official First Name:
MASOUD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
575-627-9110

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  ST96299 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: MD2007-0020 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: MD2011-0742 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: MD2012-0244 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 96299 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 800521089 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: Z2565 . This is a "MEDICAID GROUP NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1238400001 . This is a "PALMETTO GBA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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