Provider Demographics
NPI:1518277417
Name:MASOUD KHORSAND-SAHBAIE, MD PA
Entity Type:Organization
Organization Name:MASOUD KHORSAND-SAHBAIE, MD PA
Other - Org Name:KYMERA INDEPENDENT PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS SYSTEMS/CREDENTIALING MGR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-627-9508
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-627-9508
Mailing Address - Fax:877-749-7764
Practice Address - Street 1:101 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5713
Practice Address - Country:US
Practice Address - Phone:575-234-1471
Practice Address - Fax:575-234-1473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASOUD KHORSAND-SAHBAIE, MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-14
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0215207R00000X
NM96299207RH0003X
NMMD2012-0091207RH0003X
NMMD2011-0742207RH0003X
NMMD2012-0244207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ2565Medicaid
NM1238400002Medicare NSC
NMZ2565Medicaid