Basic Information
| Provider Information | |||||||||
| NPI: | 1841546793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDRISS | ||||||||
| FirstName: | HAWA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HARRODSBURG RD STE A300 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593134744 | ||||||||
| FaxNumber: | 8592765939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2012 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 51370 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 51370 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RP1001X | 51370 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.