Provider Demographics
NPI:1275695710
Name:MAHMOUD, AHMED A
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:A
Last Name:MAHMOUD
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 1:3200 GREENFIELD ROAD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1800
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-271-5565
Practice Address - Fax:313-563-3342
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47348207RC0200X
MI4301092438207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN251904600Medicaid
810000160Medicare ID - Type Unspecified
MNI 26856Medicare UPIN