Basic Information
| Provider Information | |||||||||
| NPI: | 1639203847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHMOUD | ||||||||
| FirstName: | MOHAMAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 ALEXANDER ST | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146074039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859228585 | ||||||||
| FaxNumber: | 5859228555 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859228585 | ||||||||
| FaxNumber: | 5859221399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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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 | 207V00000X | 036117782 | IL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 269464 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036117782 | 01 | IL | IL LICENSE | OTHER | 1639203847 | 05 | MI | MEDICAID |