Basic Information
| Provider Information | |||||||||
| NPI: | 1194719286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHMOUD | ||||||||
| FirstName: | SHABAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 COSHOCTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430501440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403939000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1330 COSHOCTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430501440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403939000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 74977 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2083632 | 05 | OH | MEDICAID | 000000207469 | 01 | ANTHEM | OTHER |