Provider Demographics
NPI:1326100439
Name:4500 GULFWAY MEDICAL MANAGEMENT PA
Entity Type:Organization
Organization Name:4500 GULFWAY MEDICAL MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ISAM
Authorized Official - Middle Name:NAZMI
Authorized Official - Last Name:ANABTAWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-982-5110
Mailing Address - Street 1:PO BOX 3756
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77643
Mailing Address - Country:US
Mailing Address - Phone:409-982-5110
Mailing Address - Fax:409-982-8196
Practice Address - Street 1:4500 GULFWAY DRIVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-982-5110
Practice Address - Fax:409-982-8196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B20902Medicare UPIN
TX0078AXMedicare PIN