Healthcare Provider Details

I. General information

NPI: 1700909934
Provider Name (Legal Business Name): JAMAL M ABUSHAALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST BIW 6033
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST BIW 6033
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2331
  • Fax: 706-721-7531
Mailing address:
  • Phone: 706-721-2331
  • Fax: 706-721-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number001850
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberL8254
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: