Provider Demographics
NPI:1043355290
Name:DR. ABDULKADER DAHHAN PSC
Entity Type:Organization
Organization Name:DR. ABDULKADER DAHHAN PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RMA
Authorized Official - Phone:606-573-1085
Mailing Address - Street 1:120 PROFESSIONAL LN STE 101
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2601
Mailing Address - Country:US
Mailing Address - Phone:606-573-1085
Mailing Address - Fax:606-573-9956
Practice Address - Street 1:120 PROFESSIONAL LN STE 101
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2601
Practice Address - Country:US
Practice Address - Phone:606-573-1085
Practice Address - Fax:606-573-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64171929Medicaid
C65543Medicare UPIN
1420901Medicare ID - Type Unspecified