Provider Demographics
NPI: | 1760444186 |
---|---|
Name: | BISHARA, HANY M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | HANY |
Middle Name: | M |
Last Name: | BISHARA |
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: | PO BOX 60280 |
Mailing Address - Street 2: | MCKESSON CORP |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29419-0280 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-569-4020 |
Mailing Address - Fax: | 770-237-4980 |
Practice Address - Street 1: | 833 CAMPBELL HILL ST |
Practice Address - Street 2: | SUITE 111 |
Practice Address - City: | MARIETTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30060 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-424-7800 |
Practice Address - Fax: | 770-426-8572 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-03 |
Last Update Date: | 2008-02-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 032874 | 207ZP0102X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 450161 | Other | BLUE CROSS |
GA | 00531572A | Medicaid | |
GA | 220020959 | Other | RAILROAD MEDICARE |
GA | 22BDCCH | Medicare PIN | |
GA | 220020959 | Other | RAILROAD MEDICARE |