Basic Information
| Provider Information | |||||||||
| NPI: | 1063430932 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMJAD RASS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61353 SOUTHGATE RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437256607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404358585 | ||||||||
| FaxNumber: | 7404543790 | ||||||||
| Practice Location | |||||||||
| Address1: | 61353 SOUTHGATE RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437256607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404358585 | ||||||||
| FaxNumber: | 7404543790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RASS | ||||||||
| AuthorizedOfficialFirstName: | AMJAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 7404358585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DD6530 | 01 | OH | RR M/C GROUP PROV # | OTHER | 2612935 | 05 | OH | MEDICAID |