Provider Demographics
NPI:1669603957
Name:JEFEE BAHLOUL, HUSSAM ALDEEN (MD)
Entity type:Individual
Prefix:
First Name:HUSSAM ALDEEN
Middle Name:
Last Name:JEFEE BAHLOUL
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-2148
Practice Address - Fax:508-856-5990
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0518582084P0800X, 2084P0802X
MA2619502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110103661AMedicaid
CTD400160566OtherMEDICARE DR. BAHLOUL
CT008050854OtherMEDICAID DR. BAHLOUL
CTD400160566OtherMEDICARE DR. BAHLOUL
CT004217099OtherAPT PCS LONG WHARF MEDICAID
CT008050854OtherMEDICAID DR. BAHLOUL
CTC01033OtherPCS MEDICARE PTAN
CT008022626OtherORCHARD HILL MEDICAID
CT008039745OtherPCS MEDICAID (BPT)