Basic Information
| Provider Information | |||||||||
| NPI: | 1942479829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AHMAD KADDURAH MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 956 | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484800956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102337103 | ||||||||
| FaxNumber: | 8102339710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HURLEY PLZ | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485035902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102579000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | KADDURAH | ||||||||
| AuthorizedOfficialFirstName: | AHMAD | ||||||||
| AuthorizedOfficialMiddleName: | KASIM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8102337103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301063683 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 104612989 | 05 | MI | MEDICAID |