Provider Demographics
NPI:1467584516
Name:ALBASHA, IMAD (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:ALBASHA
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 1:1639 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1449
Mailing Address - Country:US
Mailing Address - Phone:815-229-7227
Mailing Address - Fax:815-229-7288
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-229-7227
Practice Address - Fax:815-229-7288
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360793352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079335Medicaid
IL912800Medicare ID - Type Unspecified
IL036079335Medicaid