Healthcare Provider Details

I. General information

NPI: 1215978689
Provider Name (Legal Business Name): AHMED A TARANISSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

IV. Provider business mailing address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax: 573-582-1212
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2000165586
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2000165586
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: