Provider Demographics
NPI:1770596215
Name:MOHSEN, ALY MOHAMED (MD)
Entity type:Individual
Prefix:MR
First Name:ALY
Middle Name:MOHAMED
Last Name:MOHSEN
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 1:501 N MAIN ST
Mailing Address - Street 2:SUIT C
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-2743
Mailing Address - Country:US
Mailing Address - Phone:866-543-3621
Mailing Address - Fax:866-543-3621
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:SUIT C
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3535
Practice Address - Country:US
Practice Address - Phone:866-543-3621
Practice Address - Fax:866-543-3621
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-37152081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150491001Medicaid
43-1551638OtherTAX ID
ARA 10451Medicare UPIN
AR5M703Medicare ID - Type Unspecified