Basic Information
| Provider Information | |||||||||
| NPI: | 1841436763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVICENNA MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 132921 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773932921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553725454 | ||||||||
| FaxNumber: | 9365854657 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773042808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553725454 | ||||||||
| FaxNumber: | 2814084108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALI-KHAN | ||||||||
| AuthorizedOfficialFirstName: | MUJTABA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8553725454 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | M3450 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.