=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285745653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | M AZAM MOHIUDDIN M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 02/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8110 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19152-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-695-0331
-----------------------------------------------------
Fax | 215-695-0325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8110 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19152-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-695-0331
-----------------------------------------------------
Fax | 215-695-0325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | MD-037150L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD037150L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------