Healthcare Provider Details

I. General information

NPI: 1114389970
Provider Name (Legal Business Name): MOHAMED MAHMOUD ALI AHMED FARRAG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

500 UNIVERSITY DR
HERSHEY PA
17033-2391
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-8521
  • Fax:
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD472206
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier103881321
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier15089158
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH
# 3
Identifier1114389970
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: