Provider Demographics
NPI:1720069388
Name:ALAM, MASROOR (MD)
Entity Type:Individual
Prefix:
First Name:MASROOR
Middle Name:
Last Name:ALAM
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 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:STE 258
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS PSC
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY36170207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0982843Medicaid
IN200320150Medicaid
611077369OtherTAX ID
KY64028475Medicaid
311585770 1720069388OtherHEALTHNET
000000192691OtherANTHEM BLUE SHIELD
000000642262OtherANTHEM
11179782OtherCAQH
KY64028475Medicaid
311585770 1720069388OtherHEALTHNET
611077369OtherTAX ID
OH0982843Medicaid