Healthcare Provider Details

I. General information

NPI: 1194187245
Provider Name (Legal Business Name): BABAK AMROLLAHIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715A DIVISION ST
BILOXI MS
39530-2209
US

IV. Provider business mailing address

PO BOX 475
BILOXI MS
39533-0475
US

V. Phone/Fax

Practice location:
  • Phone: 228-374-2494
  • Fax: 228-396-3457
Mailing address:
  • Phone: 228-374-2494
  • Fax: 228-396-3457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31547
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: