Healthcare Provider Details

I. General information

NPI: 1952367799
Provider Name (Legal Business Name): MARIYAM A HUSSAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 N MAIN ST
FUQUAY VARINA NC
27526-9231
US

IV. Provider business mailing address

2136 N MAIN ST
FUQUAY VARINA NC
27526-9231
US

V. Phone/Fax

Practice location:
  • Phone: 919-567-1607
  • Fax: 919-567-1622
Mailing address:
  • Phone: 919-567-1607
  • Fax: 919-567-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200101219
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number200101219
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number200101219
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number200101219
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number200101219
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: