Healthcare Provider Details

I. General information

NPI: 1265584569
Provider Name (Legal Business Name): AHMED CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DESMOND ST
SAYRE PA
18840-2002
US

IV. Provider business mailing address

102 DESMOND ST
SAYRE PA
18840-2002
US

V. Phone/Fax

Practice location:
  • Phone: 570-882-9939
  • Fax: 570-882-1320
Mailing address:
  • Phone: 570-882-9939
  • Fax: 570-882-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD046924L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. IBRAHIM AHMED
Title or Position: OWNER
Credential: M.D.
Phone: 570-882-9939