Healthcare Provider Details

I. General information

NPI: 1124021829
Provider Name (Legal Business Name): BASSEM I RAZZOUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

IV. Provider business mailing address

10330 N MERIDIAN ST SUITE 201
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-4673
  • Fax: 317-338-3227
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number01063092A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: