Healthcare Provider Details

I. General information

NPI: 1184112856
Provider Name (Legal Business Name): DR. RAJAB IDRISS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 S UNIVERSITY BLVD UNIT 6000
MOBILE AL
36608-3274
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-5555
  • Fax: 251-660-5559
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number275246
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number275426
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberL.5314SP
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: