Basic Information
| Provider Information | |||||||||
| NPI: | 1457435901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITANI | ||||||||
| FirstName: | ABEDALRAHMAN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | 4178753922 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | 4178753922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/03/2012 | ||||||||
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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 | 207RP1001X | 2004029639 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 207460502 | 05 | MO | MEDICAID |