Basic Information
| Provider Information | |||||||||
| NPI: | 1730446303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENVILLE NEUROLOGY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | 6623329878 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | 6623329878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | AHMED | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6623329872 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 16065 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00119831 | 05 | MS | MEDICAID | 512I130029 | 01 | MS | MEDICARE PART B | OTHER |