Healthcare Provider Details

I. General information

NPI: 1669624813
Provider Name (Legal Business Name): HANI ALBOUSHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 KOHLER MEMORIAL DR 306
SHEBOYGAN WI
53081-3129
US

IV. Provider business mailing address

3919 MENDOCINO LN 306
SHEBOYGAN WI
53083-1883
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-4467
  • Fax: 920-459-1408
Mailing address:
  • Phone: 701-340-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number62254-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: