Provider Demographics
NPI:1942479829
Name:AHMAD KADDURAH MD PC
Entity Type:Organization
Organization Name:AHMAD KADDURAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:KASIM
Authorized Official - Last Name:KADDURAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-233-7103
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-0956
Mailing Address - Country:US
Mailing Address - Phone:810-233-7103
Mailing Address - Fax:810-233-9710
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-257-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063683174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104612989Medicaid