Provider Demographics
NPI:1477841633
Name:ABUSAMRA, AHMED
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:ABUSAMRA
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:317-621-9002
Mailing Address - Fax:
Practice Address - Street 1:1402 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0963
Practice Address - Country:US
Practice Address - Phone:317-887-7957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099117282N00000X
IN01072955A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201179780Medicaid
IN266180242Medicare PIN