Basic Information
| Provider Information | |||||||||
| NPI: | 1053372649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTAR | ||||||||
| FirstName: | BASSAM | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 818 N EMPORIA ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162624467 | ||||||||
| FaxNumber: | 3162620706 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 N EMPORIA ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162624467 | ||||||||
| FaxNumber: | 3162620706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 0427872 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1286700003 | 01 | KS | DMERC REGION 1 | OTHER | 1286700007 | 01 | KS | DMERC REGION 1 | OTHER | 1286700009 | 01 | KS | DMERC REGION 1 | OTHER | 1286700013 | 01 | KS | DMERC REGION 1 | OTHER | 1286700005 | 01 | KS | DMERC REGION 1 | OTHER | 1286700008 | 01 | KS | DMERC REGION 1 | OTHER | 100337210A | 05 | KS | MEDICAID | 1286700006 | 01 | KS | DMERC REGION 1 | OTHER | 1286700011 | 01 | KS | DMERC REGION 1 | OTHER | 1286700015 | 01 | KS | DMERC REGION 1 | OTHER | 1286700002 | 01 | KS | DMERC REGION 1 | OTHER | 1286700012 | 01 | KS | DMERC REGION 1 | OTHER | 1286700004 | 01 | KS | DMERC REGION 1 | OTHER | 12867010010 | 01 | KS | DMERC REGION 1 | OTHER |