Provider Demographics
NPI:1639279342
Name:MAMDOUH RIAD MD PC
Entity type:Organization
Organization Name:MAMDOUH RIAD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-202-5823
Mailing Address - Street 1:5421 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9561
Mailing Address - Country:US
Mailing Address - Phone:402-525-4201
Mailing Address - Fax:508-865-1109
Practice Address - Street 1:51 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3109
Practice Address - Country:US
Practice Address - Phone:508-790-4568
Practice Address - Fax:508-865-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17540OtherBLUE SHIELD
MA9702181Medicaid
MA9702181Medicaid
MA0003937Medicare PIN