Provider Demographics
NPI:1821175621
Name:AL-BASSAM, MAHDI SALEH (MD)
Entity Type:Individual
Prefix:
First Name:MAHDI
Middle Name:SALEH
Last Name:AL-BASSAM
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 1:17206 KINNEAR RD. N.E.
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-3022
Mailing Address - Country:US
Mailing Address - Phone:281-701-4630
Mailing Address - Fax:
Practice Address - Street 1:7600 BEECHNUT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-4302
Practice Address - Country:US
Practice Address - Phone:281-701-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0779207RI0011X, 207RC0000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0086XGOtherBLUESHIELD/BLUECROSS
TXP01080869OtherMEDICARE RAILROAD/PALMETTO GBA
TXB20826Medicare UPIN
TXTXB149633Medicare PIN
TX84V320OtherBCBS
TXB20826Medicare UPIN
TX00L21LMedicare ID - Type Unspecified