Healthcare Provider Details

I. General information

NPI: 1467573436
Provider Name (Legal Business Name): MR. AHMED S. GOMAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BRACKLEY LN SOUTH BARRINGTON
SOUTH BARRINGTON IL
60010-6128
US

IV. Provider business mailing address

6 BRACKLEY LN SOUTH BARRINGTON
SOUTH BARRINGTON IL
60010-6128
US

V. Phone/Fax

Practice location:
  • Phone: 847-776-6822
  • Fax: 847-705-9838
Mailing address:
  • Phone: 847-776-6822
  • Fax: 847-705-9838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number238000112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: