Basic Information
| Provider Information | |||||||||
| NPI: | 1376653634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHMED | ||||||||
| FirstName: | MIRZA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERY STREET | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023151458 | ||||||||
| FaxNumber: | 5024791425 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 W 5TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407412112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068644040 | ||||||||
| FaxNumber: | 6068643500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 31393 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 034761 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 31393 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 000715448AA | 05 | GA | MEDICAID | 000715448AC | 05 | GA | MEDICAID | 000715448AD | 05 | GA | MEDICAID | 000715448AP | 05 | GA | MEDICAID | 319761 | 01 | GA | WELL CARE (MEDICAID CMO) | OTHER | 708612 | 01 | GA | BCBS EDI # | OTHER | 7100366800 | 05 | KY | MEDICAID | 607859800 | 01 | GA | DEPT OF LABOR # | OTHER | P00180131 | 01 | GA | RAILROAD PROV # | OTHER | 000715448AB | 05 | GA | MEDICAID |