Healthcare Provider Details

I. General information

NPI: 1871586453
Provider Name (Legal Business Name): MAMOUN R PACHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S DOUGLAS AVE
SYLACAUGA AL
35150-2951
US

IV. Provider business mailing address

16 S DOUGLAS AVE
SYLACAUGA AL
35150-2951
US

V. Phone/Fax

Practice location:
  • Phone: 256-245-2269
  • Fax: 256-245-2260
Mailing address:
  • Phone: 256-245-2269
  • Fax: 256-245-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8767
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: