Basic Information
| Provider Information | |||||||||
| NPI: | 1346279460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABDUL-RAZAK | ||||||||
| FirstName: | BASIMA | ||||||||
| MiddleName: | MUHAMMED | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MD LLC | ||||||||
| OtherFirstName: | RAZAK | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750412 | ||||||||
| FaxNumber: | 4079750413 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750412 | ||||||||
| FaxNumber: | 4079750413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C53991 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301068389 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | ME134057 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | ME134057 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0634484 | 01 | BCBS/BCN PIN NUMBER | OTHER | 146412 | 01 | GREAT LAKES HEALTH PLAN# | OTHER | 16502 | 01 | HEALTH PLAN OF MICHIGAN# | OTHER | 16528 | 01 | MCARE PIN # | OTHER | 7686102 | 01 | AETNA PROVIDER NUMBER | OTHER | 4673447-10 | 05 | MI | MEDICAID | 00000005503A | 01 | CAPE PIN NUMBER | OTHER | 023862 | 01 | MIDWEST PIN # | OTHER | 4331048-10 | 05 | MI | MEDICAID |