Healthcare Provider Details

I. General information

NPI: 1396918546
Provider Name (Legal Business Name): KAMAL KHAN RAISANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HARPER COURT
TUSCALOOSA AL
35401
US

IV. Provider business mailing address

115 HARPER COURT
TUSCALOOSA AL
35401
US

V. Phone/Fax

Practice location:
  • Phone: 205-366-3010
  • Fax: 205-366-3012
Mailing address:
  • Phone: 205-366-3010
  • Fax: 205-366-3012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number21461
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21461
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: