Basic Information
| Provider Information | |||||||||
| NPI: | 1396787479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIFAI | ||||||||
| FirstName: | MOHAMAD | ||||||||
| MiddleName: | HYTHAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIFAI | ||||||||
| OtherFirstName: | M. HYTHAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 E 89TH AVE | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197562900 | ||||||||
| FaxNumber: | 2197562910 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E 89TH AVE | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197562900 | ||||||||
| FaxNumber: | 2197562910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 01035906 | IN | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 087388 | 01 | IN | ANTHEM | OTHER | 100214490A | 05 | IN | MEDICAID | 129164100 | 01 | IN | INDIANA DEPT OF LABOR | OTHER | 140000847 | 01 | IN | PALMETTO RR MEDICARE | OTHER |