Provider Demographics
NPI:1376575126
Name:RADWAN, AHMED A (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:A
Last Name:RADWAN
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 1:1512 N GREEN MOUNT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1953
Mailing Address - Country:US
Mailing Address - Phone:618-624-1860
Mailing Address - Fax:618-624-1863
Practice Address - Street 1:670 PIERCE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2579
Practice Address - Country:US
Practice Address - Phone:618-206-2070
Practice Address - Fax:618-206-2071
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114529207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI63670Medicare UPIN