Basic Information
| Provider Information | |||||||||
| NPI: | 1487768172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AYASS LUNG CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 S ABE ST | ||||||||
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| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769036305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256557969 | ||||||||
| FaxNumber: | 3256557976 | ||||||||
| Practice Location | |||||||||
| Address1: | 3021 GREEN MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769046975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252231800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | AYASS | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD-AMMAR | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3256557969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | L2116 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 168067001 | 05 | TX | MEDICAID | 0027LW | 01 | TX | BCBS OF TX GROUP# | OTHER |