Basic Information
Provider Information | |||||||||
NPI: | 1871609933 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALASSAS | ||||||||
FirstName: | MOHAMED | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25608 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841250608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063204476 | ||||||||
FaxNumber: | 2065687043 | ||||||||
Practice Location | |||||||||
Address1: | 1221 MADISON ST | ||||||||
Address2: | STE 1401 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981043588 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063866700 | ||||||||
FaxNumber: | 2063866706 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 04/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | ME106619 | FL | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | 23169 | WV | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | MD60693493 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 189567306C | 05 | GA |   | MEDICAID | 558254 | 01 | FL | WELLCARE | OTHER | 9357554 | 01 | FL | CIGNA | OTHER | 002392800 | 05 | FL |   | MEDICAID | 281173106 | 05 | FL |   | MEDICAID | 189567306E(JHF) | 05 | GA |   | MEDICAID |