Healthcare Provider Details

I. General information

NPI: 1639565294
Provider Name (Legal Business Name): NIDAL BASSAM OMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MOBILE INFIRMARY CIR STE 410
MOBILE AL
36607-3512
US

IV. Provider business mailing address

3 MOBILE INFIRMARY CIR STE 410
MOBILE AL
36607-3512
US

V. Phone/Fax

Practice location:
  • Phone: 251-232-3314
  • Fax:
Mailing address:
  • Phone: 251-435-6850
  • Fax: 251-435-6859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD.36032
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: