=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770684326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EHSAN M HADI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 01/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6555 COYLE AVENUE
-----------------------------------------------------
City | CARMICHAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-536-3670
-----------------------------------------------------
Fax | 916-536-2480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 DATA DRIVE PHYSICIAN SUPPPRT SERVICES
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-7956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-379-2948
-----------------------------------------------------
Fax | 916-858-7065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | BH8093320
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A102040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | A102040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------