Basic Information
Provider Information | |||||||||
NPI: | 1528046315 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUSEF | ||||||||
FirstName: | AMIR | ||||||||
MiddleName: | HABIBOLLAH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 261164 | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708261164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253877070 | ||||||||
FaxNumber: | 2253877700 | ||||||||
Practice Location | |||||||||
Address1: | 3600 FLORIDA BLVD | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708063842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253877070 | ||||||||
FaxNumber: | 2253877700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 01/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD.200558 | LA | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 207R00000X | 200558 | LA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1722006 | 05 | LA |   | MEDICAID | 1528046315 | 01 | LA | NPI | OTHER | P00310461 | 01 | LA | RAILROAD | OTHER |