Basic Information
Provider Information | |||||||||
NPI: | 1467408344 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AHSAN | ||||||||
FirstName: | MUHAMMAD | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1221 BOWERS ST | ||||||||
Address2: | UNIT 2653 | ||||||||
City: | BIRMINGHAM | ||||||||
State: | MI | ||||||||
PostalCode: | 480127107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2482007756 | ||||||||
FaxNumber: | 2482813535 | ||||||||
Practice Location | |||||||||
Address1: | 715 S TAFT AVE | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | OH | ||||||||
PostalCode: | 434203237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193327321 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
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 | 35083611A | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208VP0000X | 4301097463 | MI | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 2463543 | 05 | OH |   | MEDICAID | 000000336858 | 01 |   | BCBS CLARK COUNTY | OTHER | 000000509617 | 01 |   | BCBS FAIRFIELD HOS | OTHER | P00157619 | 01 |   | MEDICARE RR | OTHER | P00303491 | 01 |   | RAIL ROAD MEDICARE | OTHER | 000000336869 | 01 |   | BCBS | OTHER |