Provider Demographics
NPI:1821047044
Name:ANSARI, MOHAMMAD TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:TARIQ
Last Name:ANSARI
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE B480
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-4200
Practice Address - Fax:864-454-4205
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15259207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC290010760OtherRR MEDICARE
SC152596Medicaid
SCE620067951Medicare PIN
SC152596Medicaid
SC57-6007863082OtherBLUE CHOICE OF SC
SC152596Medicaid
SCE620066904Medicare PIN
SC4244846OtherAETNA
SCE62006Medicare UPIN