Provider Demographics
NPI:1235121237
Name:NUSRAT, FAHEEM B (MD)
Entity Type:Individual
Prefix:
First Name:FAHEEM
Middle Name:B
Last Name:NUSRAT
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:UNIVERSITY MEDICAL GROUP
Mailing Address - Street 2:P O BOX 1705
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7261
Mailing Address - Fax:706-774-7279
Practice Address - Street 1:1021 SILVER BLUFF RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803
Practice Address - Country:US
Practice Address - Phone:803-648-0587
Practice Address - Fax:803-648-9846
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044043207R00000X
SCMD38409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000788081EMedicaid
GA111811OtherMEDICARE FQHC
GA342410OtherWELLCARE
GA11SCCWTOtherMEDICARE FFS
GA341629OtherWELLCARE
GAGRP1619OtherMEDICARE FFS GROUP
GA000788081BMedicaid
GA10057307OtherAMERIGROUP
GA341628OtherWELLCARE
GA000471809AOtherMEDICAID FQHC
GA000471809BMedicaid
GA341630OtherWELLCARE
P00015170OtherMEDICARE RR RETIRED
GA111812OtherMEDICARE FQHC
GA111814OtherMEDICARE FQHC
G67104Medicare UPIN