MEDICARE: DR. IMAD A.R. IDRISS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	7841	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134127947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IMAD A.R. IDRISS M.D.

Provider Business Mailing Address
First Line	:	2427 S TELSHOR BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-5049
Country	:	US
Telephone Number	:	575-522-1059
Fax Number	:	575-522-3652

Provider Business Practice Location Address
First Line	:	2427 S TELSHOR BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-5049
Country	:	US
Telephone Number	:	575-522-1059
Fax Number	:	575-522-3652

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	10/31/2008

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