Provider Demographics
NPI:1225009426
Name:ASSAF, BASSAM A (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:A
Last Name:ASSAF
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 1:4370 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6867
Mailing Address - Country:US
Mailing Address - Phone:309-517-6891
Mailing Address - Fax:309-517-6895
Practice Address - Street 1:4370 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6867
Practice Address - Country:US
Practice Address - Phone:309-517-6891
Practice Address - Fax:309-517-6895
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360857652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08132080OtherBLUE CROSS BLUE SHIELD
IL036085765Medicaid
IL036085765Medicaid
ILK21750Medicare ID - Type Unspecified
IL08132080OtherBLUE CROSS BLUE SHIELD