Provider Demographics
NPI:1063832368
Name:GHANEM, AHMED MOHAMMED MOAMEN
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:MOHAMMED MOAMEN
Last Name:GHANEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8535 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4811
Mailing Address - Country:US
Mailing Address - Phone:929-333-0369
Mailing Address - Fax:
Practice Address - Street 1:503 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4811
Practice Address - Country:US
Practice Address - Phone:718-254-0182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035568-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist