Provider Demographics
NPI:1467544346
Name:AMTUL R AHMAD MD SC
Entity Type:Organization
Organization Name:AMTUL R AHMAD MD SC
Other - Org Name:AMTUL R AHMAD MD SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMTUL
Authorized Official - Middle Name:REHMAN
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-564-0611
Mailing Address - Street 1:3601 30TH AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1695
Mailing Address - Country:US
Mailing Address - Phone:262-564-0611
Mailing Address - Fax:262-564-0601
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-564-0611
Practice Address - Fax:262-564-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40006020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32466300Medicaid
BA3947477OtherDEA
G41727Medicare UPIN