=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487092334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIRAJ HEALTHCARE INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2013
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3876 TURKEYFOOT RD
-----------------------------------------------------
City | ELSMERE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41018-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-342-4087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6716
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41022-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-342-4087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMMAD FATTAL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 859-342-4087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------