Provider Demographics
NPI:1275610719
Name:HUSSAIN, IMTIAZ (MD)
Entity Type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:
Last Name:HUSSAIN
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 1:106 KEENE MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-7910
Mailing Address - Country:US
Mailing Address - Phone:859-533-1467
Mailing Address - Fax:
Practice Address - Street 1:306 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSON
Practice Address - State:KY
Practice Address - Zip Code:41503-4095
Practice Address - Country:US
Practice Address - Phone:606-237-4943
Practice Address - Fax:606-237-1740
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29223207P00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1473277OtherUMWA HEALTH & RETIREMENT
000000202232OtherBCBS
010721900OtherFEDERAL BLACK LUNG
611265801OtherBRICK STREET ADMINISTRATI
KY64292238Medicaid
WV0075636000Medicaid
WVHU4031071Medicare PIN
010721900OtherFEDERAL BLACK LUNG
611265801OtherBRICK STREET ADMINISTRATI
KY64292238Medicaid
GA110099930Medicare PIN