Provider Demographics
NPI:1912199522
Name:IM PHYSICIAN PLLC
Entity Type:Organization
Organization Name:IM PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOLHASSANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-443-0062
Mailing Address - Street 1:8704 E GAIL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6646
Mailing Address - Country:US
Mailing Address - Phone:480-443-0062
Mailing Address - Fax:480-443-3587
Practice Address - Street 1:3501 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5648
Practice Address - Country:US
Practice Address - Phone:480-513-2727
Practice Address - Fax:480-513-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31935173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH97495Medicare UPIN