Basic Information
Provider Information | |||||||||
NPI: | 1770591455 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAHMAN | ||||||||
FirstName: | MOHAMMAD | ||||||||
MiddleName: | ANISUR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1039 SPOTSWOOD CIR | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | GA | ||||||||
PostalCode: | 308095492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3475745585 | ||||||||
FaxNumber: | 7068233960 | ||||||||
Practice Location | |||||||||
Address1: | 1 FREEDOM WAY | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309046258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067330188 | ||||||||
FaxNumber: | 7068233960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME132633 | FL | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 25MA06837700 | NJ | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 213014 | NY | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 86643 | GA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 1677409-003 | 01 | NY | CIGNA INSURANCE | OTHER | 275060 | 01 | NY | WELL CARE | OTHER | 2I205 | 01 | NY | BLUE CROSS, BLUE SHIELD | OTHER | 4C3393 | 01 | NY | HEALTH-NET | OTHER | 7664365 | 01 | NY | AETNA POS AND PPO | OTHER | 2166811 | 01 | NY | UNITED HEALTH CARE -COMME | OTHER | 2300691 | 01 | NY | UNITED HEALTHCARE GOVRNME | OTHER | P2577111 | 01 | NY | OXFORD HEALTH PLANS | OTHER | 2879068 | 01 | NY | AETNA HMO | OTHER |