Provider Demographics
NPI:1073568895
Name:OMAR, BASSAM A (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:A
Last Name:OMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-445-8242
Mailing Address - Fax:251-445-8250
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:BLDG. C
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-445-8242
Practice Address - Fax:251-445-8250
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18169207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126751Medicaid
AL51513255OtherBLUE CROSS
AL009908725Medicaid
AL51513252OtherBLUE CROSS
LA1165891Medicaid
AL25-10824OtherUNITED HEALTH CARE
AL009908705Medicaid
AL009908705Medicaid
MS00126751Medicaid
AL51513252OtherBLUE CROSS