Provider Demographics
NPI:1205977634
Name:SHUKRALLAH, BASSAM N (MD)
Entity type:Individual
Prefix:
First Name:BASSAM
Middle Name:N
Last Name:SHUKRALLAH
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 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7800
Mailing Address - Fax:501-812-7777
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6342
Practice Address - Country:US
Practice Address - Phone:501-223-2860
Practice Address - Fax:501-223-2258
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16164208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173526Medicaid
OHH455910Medicare PIN