Provider Demographics
NPI:1508808635
Name:BOUHASIN, ANDRE P (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:P
Last Name:BOUHASIN
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 1:513 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1439
Mailing Address - Country:US
Mailing Address - Phone:573-701-0090
Mailing Address - Fax:
Practice Address - Street 1:513 W PINE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1439
Practice Address - Country:US
Practice Address - Phone:573-701-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004002409207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO947071631OtherMERCY HEALTH
MO426403OtherHEALTHLINK
MO206138802Medicaid
MO124884OtherBLUE CROSS
MO124884OtherBLUE CROSS
MO426403OtherHEALTHLINK