Healthcare Provider Details

I. General information

NPI: 1376575126
Provider Name (Legal Business Name): AHMED A. RADWAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

IV. Provider business mailing address

1512 N GREEN MOUNT RD SUITE 200
O FALLON IL
62269-1953
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-2070
  • Fax: 618-206-2071
Mailing address:
  • Phone: 618-624-1860
  • Fax: 618-624-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036114529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: