Provider Demographics
NPI:1598703761
Name:ALTAQI, BASEL (MD)
Entity Type:Individual
Prefix:
First Name:BASEL
Middle Name:
Last Name:ALTAQI
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 1:6707 POWERS BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5455
Mailing Address - Country:US
Mailing Address - Phone:440-886-2509
Mailing Address - Fax:440-886-2547
Practice Address - Street 1:6707 POWERS BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5455
Practice Address - Country:US
Practice Address - Phone:440-886-2509
Practice Address - Fax:440-886-2547
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39320208M00000X
OH35085185207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000362550OtherBCBS PROVIDER NUMBER
KY39320OtherKENTUCKY MEDICAL LICENSE
KY64097439Medicaid
KY39320OtherKENTUCKY MEDICAL LICENSE
0903664Medicare PIN
0601435Medicare PIN
0935320Medicare PIN
KYP00281032Medicare PIN