Provider Demographics
NPI:1386718401
Name:CHABENNE, BAHJAT SAMI (MD)
Entity type:Individual
Prefix:
First Name:BAHJAT
Middle Name:SAMI
Last Name:CHABENNE
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1000
Practice Address - Fax:317-355-5440
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024613A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000764829OtherANTHEM
IN100058480AMedicaid
INP01211599OtherRR MEDICARE PTAN
IN100058480AMedicaid
INC24276Medicare UPIN
INM400029061Medicare PIN