Basic Information
Provider Information | |||||||||
NPI: | 1104911650 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ISMAIL | ||||||||
FirstName: | AHMAD | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 MOYE BLVD STE 3E149 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278344300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527445258 | ||||||||
FaxNumber: | 2527444887 | ||||||||
Practice Location | |||||||||
Address1: | 2209 S STERLING ST STE 600 | ||||||||
Address2: |   | ||||||||
City: | MORGANTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286554092 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8285804577 | ||||||||
FaxNumber: | 8285804599 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 09/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD13041 | RI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 2013-01144 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 39138 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 2013-01144 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 110087997A | 05 | MA |   | MEDICAID | 39138A | 05 | SC |   | MEDICAID | 001233601 | 01 | RI | MEDICARE PTAN | OTHER | AI77047 | 05 | RI |   | MEDICAID |