Provider Demographics
NPI:1477660579
Name:AHMED, NOOR (MD)
Entity Type:Individual
Prefix:
First Name:NOOR
Middle Name:
Last Name:AHMED
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 1:2 MEMORIAL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-465-6401
Mailing Address - Fax:618-465-0411
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-465-6401
Practice Address - Fax:618-465-0411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336021259208200000X
MO35778208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056586Medicaid
MO203105309Medicaid
MO203105309Medicaid
ILD10061Medicare UPIN
IL036056586Medicaid
MO000001216Medicare ID - Type Unspecified