Provider Demographics
NPI:1083879217
Name:IMAD IDRISS MD PA
Entity Type:Organization
Organization Name:IMAD IDRISS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-522-1059
Mailing Address - Street 1:2427 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2427 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5049
Practice Address - Country:US
Practice Address - Phone:575-522-1059
Practice Address - Fax:575-522-3652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-41207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02782Medicaid
NMC97861Medicare UPIN