Healthcare Provider Details

I. General information

NPI: 1609252329
Provider Name (Legal Business Name): AHMED SHAHAB M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-3985
  • Fax: 401-444-3986
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16635
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036145640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: