Healthcare Provider Details

I. General information

NPI: 1053725499
Provider Name (Legal Business Name): MOHANNED HASSAN MOHAMMED AHMED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 40TH AVE
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

4166 SNAPFINGER WOODS DR
DECATUR GA
30035-3411
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-7100
  • Fax: 870-541-7204
Mailing address:
  • Phone: 404-289-6199
  • Fax: 404-289-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-11695
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301104828
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number074885
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-11695
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: