Basic Information
| Provider Information | |||||||||
| NPI: | 1659329050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUSSEIN OMAR, PHYSICIAN, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PAIN CONTROL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 558 | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127340558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452920078 | ||||||||
| FaxNumber: | 8452923244 | ||||||||
| Practice Location | |||||||||
| Address1: | 1885 STATE ROUTE 52 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127548309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452920078 | ||||||||
| FaxNumber: | 8452923244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OMAR | ||||||||
| AuthorizedOfficialFirstName: | HUSSEIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8452920078 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHYSICIAN, P.C. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 154839 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01624684 | 05 | NY | MEDICAID | 110306800 | 01 | NY | US DEPT OF LABOR | OTHER | 5829053 | 01 | NY | AETNA | OTHER |