Healthcare Provider Details

I. General information

NPI: 1669181780
Provider Name (Legal Business Name): MAHMOUD ABU-GHANAM PHYSICIAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
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
12734-0190
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 TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MAHMOUD ABU GHANAM
Title or Position: OWNER
Credential: MD
Phone: 845-707-3092