Provider Demographics
NPI:1164695029
Name:EL KOUSSAIMI, IDRISS (MD)
Entity Type:Individual
Prefix:
First Name:IDRISS
Middle Name:
Last Name:EL KOUSSAIMI
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 1:479 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-1828
Mailing Address - Country:US
Mailing Address - Phone:508-429-2377
Mailing Address - Fax:508-429-2607
Practice Address - Street 1:171 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-1187
Practice Address - Country:US
Practice Address - Phone:508-881-3029
Practice Address - Fax:508-881-1752
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400231485Medicare PIN
MA002365401Medicare PIN