Healthcare Provider Details

I. General information

NPI: 1356345748
Provider Name (Legal Business Name): BASSAM FAIZ BITTAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 06/20/2024
Certification Date:
Deactivation Date: 03/29/2006
Reactivation Date: 06/23/2006

III. Provider practice location address

564 W. BROAD ST.
HAZLETON PA
18201
US

IV. Provider business mailing address

564 W. BROAD ST.
HAZLETON PA
18201
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6400
  • Fax: 570-453-2353
Mailing address:
  • Phone: 570-501-6400
  • Fax: 570-453-2353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-056973
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0016887960001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier001961
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFIRST PRIORITY HEALTH ID#
# 3
IdentifierBI813177
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: