=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669624813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANI ALBOUSHI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 10/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2414 KOHLER MEMORIAL DR 306
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-457-4467
-----------------------------------------------------
Fax | 920-459-1408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3919 MENDOCINO LN 306
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53083-1883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-340-2672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 62254-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------