Provider Demographics
NPI:1770699167
Name:RIZKALLA, NASSEEM FARHAN (MD)
Entity type:Individual
Prefix:DR
First Name:NASSEEM
Middle Name:FARHAN
Last Name:RIZKALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W ICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935-9526
Mailing Address - Country:US
Mailing Address - Phone:906-265-6121
Mailing Address - Fax:906-265-4245
Practice Address - Street 1:1500 W ICE LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-8509
Practice Address - Country:US
Practice Address - Phone:906-265-9001
Practice Address - Fax:906-265-3056
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI044605208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1575282Medicaid
MI1770699167Medicaid
MI0203641031OtherBCBSM
MIE31690Medicare UPIN
MI0364103Medicare ID - Type Unspecified
MI1770699167Medicaid