Healthcare Provider Details

I. General information

NPI: 1982145157
Provider Name (Legal Business Name): BANKAI PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 11/21/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LINE AVE
SHREVEPORT LA
71101-3841
US

IV. Provider business mailing address

PO BOX 1684
SHREVEPORT LA
71165-1684
US

V. Phone/Fax

Practice location:
  • Phone: 318-716-4770
  • Fax: 318-716-4791
Mailing address:
  • Phone: 318-424-6004
  • Fax: 866-276-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM MOSSALLATI
Title or Position: OWNER
Credential: MD
Phone: 304-203-5754