Provider Demographics
NPI:1639487564
Name:SHAMSUL ALAM MD PA
Entity Type:Organization
Organization Name:SHAMSUL ALAM MD PA
Other - Org Name:THE KIDNEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMSUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-271-9393
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-1037
Mailing Address - Country:US
Mailing Address - Phone:479-271-9393
Mailing Address - Fax:479-271-0141
Practice Address - Street 1:2618 SE J ST
Practice Address - Street 2:SUITE#4
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3767
Practice Address - Country:US
Practice Address - Phone:479-271-9393
Practice Address - Fax:479-271-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4954207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5G686OtherMEDICARE GROUP PTAN