Healthcare Provider Details

I. General information

NPI: 1861066896
Provider Name (Legal Business Name): MOHAMED SALAH OMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5057
  • Fax:
Mailing address:
  • Phone: 401-444-5057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD19611
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLP05316
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberMD487739
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: