Provider Demographics
NPI:1528042975
Name:ABEDMAHMOUD, ISSA (MD)
Entity Type:Individual
Prefix:
First Name:ISSA
Middle Name:
Last Name:ABEDMAHMOUD
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:PO BOX 1096
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-1096
Mailing Address - Country:US
Mailing Address - Phone:618-988-1877
Mailing Address - Fax:618-988-8578
Practice Address - Street 1:3020 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3721
Practice Address - Country:US
Practice Address - Phone:618-988-1877
Practice Address - Fax:618-988-8578
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097793207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
416686OtherHEATHLINK
59806OtherGHP ACCESS
IL036097793Medicaid
10023061OtherBCBS IL
050625OtherHEATLH ALLIANCE
P00477017Medicare PIN
050625OtherHEATLH ALLIANCE
552110Medicare PIN