Provider Demographics
NPI:1295709764
Name:KASSAM, AMIN B (MD)
Entity type:Individual
Prefix:DR
First Name:AMIN
Middle Name:B
Last Name:KASSAM
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 1:2801 W KINNICKINNIC RIVER PKWY STE 680
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-385-1922
Mailing Address - Fax:414-385-2408
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 630
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-385-1812
Practice Address - Fax:414-385-1898
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063726L174400000X
WI61585207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001666369Medicaid
PA001666369Medicaid
PA001666369Medicaid