Basic Information
| Provider Information | |||||||||
| NPI: | 1700346368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RATTANI | ||||||||
| FirstName: | ABBAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 S JACKSON ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025612703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 529 S JACKSON ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025612703 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2019 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 125-073988 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1700346368 | 05 | IL | MEDICAID |