MEDICARE: EBRAHIM VERSI 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	207VX0201X	Gynecologic Oncology Physician	81853	MA

General Provider Information

NPI Number	:	1184732406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBRAHIM VERSI M.D.

Provider Business Mailing Address
First Line	:	11 SHEEPHILL DR
Second Line	:
City	:	GLADSTONE
State	:	NJ
Zip	:	07934-2131
Country	:	US
Telephone Number	:	908-698-2390
Fax Number	:

Provider Business Practice Location Address
First Line	:	6585 CITY WEST PKWY
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-3248
Country	:	US
Telephone Number	:	908-698-2390
Fax Number	:

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	07/08/2007

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