Basic Information
| Provider Information | |||||||||
| NPI: | 1609030394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHMOOD | ||||||||
| FirstName: | REDAH | ||||||||
| MiddleName: | Z | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 350 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4709569639 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 STONEBRIDGE PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301893768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783244444 | ||||||||
| FaxNumber: | 6783244405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301093085 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 4301093085 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 81668 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1609030394 | 05 | MI | MEDICAID | 12330056 | 01 | CAQH | OTHER |