Provider Demographics
NPI:1144281486
Name:YASSIN-KASSAB, MAHMOUD (MD)
Entity type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:YASSIN-KASSAB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MAHMOUD
Other - Middle Name:
Other - Last Name:YASSIN-KASSAB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 375B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-9370
Practice Address - Fax:317-621-5678
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01057007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000373842OtherANTHEM
INP01235995OtherMEDICARE RR PTAN
IN200425720Medicaid
INM400063329Medicare PIN
INP01235995OtherMEDICARE RR PTAN
IN266180263Medicare PIN
IN941000CCCCMedicare PIN