Healthcare Provider Details

I. General information

NPI: 1518272459
Provider Name (Legal Business Name): DR. MOHAMED BEN OMRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST GRU, DEPARTMENT OF ANESTHESIOLOGY
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

151 VERSAILLES CIR APT B
TOWSON MD
21204-6936
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3873
  • Fax: 706-721-7763
Mailing address:
  • Phone: 617-953-8493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number74217
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number74217
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: