Healthcare Provider Details

I. General information

NPI: 1992312862
Provider Name (Legal Business Name): WALL STREET MEDICAL GROUP INPATIENT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 06/11/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 SPRING ST STE 200
JEFFERSONVILLE IN
47130-4494
US

IV. Provider business mailing address

443 SPRING ST STE 200
JEFFERSONVILLE IN
47130-4494
US

V. Phone/Fax

Practice location:
  • Phone: 502-525-4376
  • Fax: 440-332-3844
Mailing address:
  • Phone: 502-525-4376
  • Fax: 440-332-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MUHAMMAD MASROOR
Title or Position: DIRECTOR/OWNER
Credential: MD
Phone: 502-500-8809