Healthcare Provider Details

I. General information

NPI: 1265160253
Provider Name (Legal Business Name): BASSAM MOHAMMED ABDO MUTHANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BASSAM ALSOJRI MD

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-6393
  • Fax: 573-884-4533
Mailing address:
  • Phone: 573-884-6393
  • Fax: 573-884-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025038446
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125081059
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: