Basic Information
| Provider Information | |||||||||
| NPI: | 1386083418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SABOURY SICHANI | ||||||||
| FirstName: | BABAK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SABOURY | ||||||||
| OtherFirstName: | BABAK | ||||||||
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| OtherCredential: | M.D., M.P.H. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 S GREENE ST, DEPT OF RADIOLOGY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103283477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST, DEPT OF RADIOLOGY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103283477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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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 | 207UN0902X | D82803 | MD | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 2085R0202X | D82803 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 814020100 | 05 | MD | MEDICAID |