Basic Information
| Provider Information | |||||||||
| NPI: | 1376521922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KADDURAH | ||||||||
| FirstName: | AHMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 956 | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484800956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102337103 | ||||||||
| FaxNumber: | 8102579710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HURLEY PLZ | ||||||||
| Address2: | ATTN: PROFESSIONAL BILLING DEPT | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485035902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102629353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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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 | 174400000X | 4301063683 | MI | N | Other Service Providers | Specialist | 2084N0402X | 4301063683 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4612989 | 05 | MI | MEDICAID |