Healthcare Provider Details

I. General information

NPI: 1487372314
Provider Name (Legal Business Name): BASSEM REZK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 W UNION HILLS DR STE 111
GLENDALE AZ
85308-2430
US

IV. Provider business mailing address

22010 N 73RD LN
GLENDALE AZ
85310-5297
US

V. Phone/Fax

Practice location:
  • Phone: 929-308-5775
  • Fax:
Mailing address:
  • Phone: 929-308-5775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR79181
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTPPA961
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number297011171
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2022027022
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: