Basic Information
| Provider Information | |||||||||
| NPI: | 1417392622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YASMEH | ||||||||
| FirstName: | BABAK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2013 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 70799 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | BY3232267556 | 01 | BY3232267556 | OTHER | 100166998 | 05 | WI | MEDICAID |