Provider Demographics
NPI:1295008563
Name:SHIRAZ HABIB KASSAM
Entity Type:Organization
Organization Name:SHIRAZ HABIB KASSAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MUBINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAWJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-922-2424
Mailing Address - Street 1:1380 MILSTEAD AVE NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3864
Mailing Address - Country:US
Mailing Address - Phone:770-922-2424
Mailing Address - Fax:770-922-8782
Practice Address - Street 1:1380 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3864
Practice Address - Country:US
Practice Address - Phone:770-922-2424
Practice Address - Fax:770-922-8782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21321207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000190506BMedicaid
GAD29907Medicare UPIN