Healthcare Provider Details

I. General information

NPI: 1285900035
Provider Name (Legal Business Name): S. RAZA, M.D., PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PROFESSIONAL LN STE 202
HARLAN KY
40831-2590
US

IV. Provider business mailing address

110 PROFESSIONAL LN STE 202
HARLAN KY
40831-2590
US

V. Phone/Fax

Practice location:
  • Phone: 606-573-8320
  • Fax: 606-573-8321
Mailing address:
  • Phone: 606-573-8320
  • Fax: 606-573-8321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number36481
License Number StateKY

VIII. Authorized Official

Name: DR. SYED MOHSIN RAZA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 606-573-8320