Healthcare Provider Details

I. General information

NPI: 1912952540
Provider Name (Legal Business Name): MAHMOUD ABU GHANAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1987 STATE ROUTE 52 STE 10
LIBERTY NY
12754-8317
US

IV. Provider business mailing address

PO BOX 190
FERNDALE NY
12734-0558
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-0078
  • Fax: 845-292-3244
Mailing address:
  • Phone: 845-292-0078
  • Fax: 845-292-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number272625
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number272625
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: