Provider Demographics
NPI:1053633461
Name:MOHAMED, AHMED SALEM (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:SALEM
Last Name:MOHAMED
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 1:412 S 34TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6021
Mailing Address - Country:US
Mailing Address - Phone:618-231-6121
Mailing Address - Fax:618-615-4380
Practice Address - Street 1:412 S 34TH ST STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6021
Practice Address - Country:US
Practice Address - Phone:618-231-6121
Practice Address - Fax:618-615-4380
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
IL036136254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136254Medicaid
ILF300255755OtherPTAN