Provider Demographics
NPI:1225298029
Name:FIDAHUSSEIN, SALMAN SHIRAZHUSSEIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SALMAN
Middle Name:SHIRAZHUSSEIN
Last Name:FIDAHUSSEIN
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 1:1551 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4139
Mailing Address - Country:US
Mailing Address - Phone:706-880-7222
Mailing Address - Fax:706-880-7223
Practice Address - Street 1:1551 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-880-7222
Practice Address - Fax:706-880-7223
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051439207R00000X
390200000X
MN105563207R00000X
MN54415207R00000X
GA73471207RP1001X
GA73741207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MNP01021732OtherRAIL ROAD - MEDICARE
WIENROLLEDMedicaid
MNENROLLEDMedicaid