Provider Demographics
NPI:1487821708
Name:M. TAHIR QAYYUM, MD, PMC
Entity Type:Organization
Organization Name:M. TAHIR QAYYUM, MD, PMC
Other - Org Name:FAMILY MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M.
Authorized Official - Middle Name:TAHIR
Authorized Official - Last Name:QAYYUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-283-2200
Mailing Address - Street 1:540 DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5013
Mailing Address - Country:US
Mailing Address - Phone:318-283-2200
Mailing Address - Fax:318-283-1200
Practice Address - Street 1:540 DURHAM STREET
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220
Practice Address - Country:US
Practice Address - Phone:318-283-2200
Practice Address - Fax:318-283-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10850R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447111Medicaid
LA1447111Medicaid