Provider Demographics
NPI:1407867484
Name:NEERAJ MAHBOOB INTERNAL MEDICINE PSC
Entity type:Organization
Organization Name:NEERAJ MAHBOOB INTERNAL MEDICINE PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NEERAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHBOOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-599-0169
Mailing Address - Street 1:515 MEMORIAL DR
Mailing Address - Street 2:STE 3
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-9157
Mailing Address - Country:US
Mailing Address - Phone:606-599-0864
Mailing Address - Fax:606-599-0869
Practice Address - Street 1:515 MEMORIAL DR
Practice Address - Street 2:STE 3
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-9157
Practice Address - Country:US
Practice Address - Phone:606-599-0864
Practice Address - Fax:606-599-0869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 363L00000X
KY700127261QP2300X
KY900231261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18-8900OtherMEDICARE RURAL HEALTH PROVIDER NUMBER
KY31-000797Medicaid
KY7100137660Medicaid
KY18-8900OtherMEDICARE RURAL HEALTH PROVIDER NUMBER