=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497391288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AHMAD ABDALI HAIDAR MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2019
-----------------------------------------------------
Last Update Date | 08/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 GOLF COURSE DR.
-----------------------------------------------------
City | CARRIERE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-699-9846
-----------------------------------------------------
Fax | 601-799-0052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1509 DULLES DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70506-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-991-9276
-----------------------------------------------------
Fax | 337-943-0846
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT
-----------------------------------------------------
Name | ALLYSON WIRTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-408-0805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------