Basic Information
| Provider Information | |||||||||
| NPI: | 1184949489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELMEZAYEN | ||||||||
| FirstName: | RABAB | ||||||||
| MiddleName: | ISMAIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD., PHD. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 50453 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 0101257730 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | P01477266 | 01 | TN | RAILROAD MEDICARE | OTHER | 1184949489 | 05 | VA | MEDICAID | 7100272730 | 05 | KY | MEDICAID | Q002518 | 05 | TN | MEDICAID | 1184949489 | 05 | NC | MEDICAID |