Basic Information
| Provider Information | |||||||||
| NPI: | 1821205063 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BASSAM M HADDAD, MD, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 GREENVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073052608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013338222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 GREENVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073052608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013338222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | HADDAD | ||||||||
| AuthorizedOfficialFirstName: | BASSAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2013338222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7402503 | 05 | NJ | MEDICAID |