=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659152254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASHA KIDNEY MEDICAL CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2023
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 296 BAILEYS GAP RD
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12528-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-428-9895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 296 BAILEYS GAP RD
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12528-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IBRAHIM RAZA PASHA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 845-428-9895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------