1093192908 NPI number — ST. LOUIS JC VAMC

Table of content: DR. MOHAMAD KHALDOUN ALNABELSI MD (NPI 1891786729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093192908 NPI number — ST. LOUIS JC VAMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. LOUIS JC VAMC
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:
SCOTT AIR FORCE BASE VA CLINIC
Provider Other Organization Name Type Code:
5
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:
1093192908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 94462
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44101-4462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-578-4409
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 W LOSEY ST
Provider Second Line Business Practice Location Address:
375TH MEDICAL GROUP
Provider Business Practice Location Address City Name:
SCOTT AIR FORCE BASE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62225-5250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-578-4409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
Authorized Official Title or Position:
NPI TEAM MEMBER
Authorized Official Telephone Number:
202-382-2579

Provider Taxonomy Codes

  • Taxonomy code: 261QV0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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