Healthcare Provider Details

I. General information

NPI: 1568439453
Provider Name (Legal Business Name): MAHMOOD ABDUL SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MEDICAL CENTER DR #B
COPPERHILL TN
37317-5000
US

IV. Provider business mailing address

PO BOX 1162
COPPERHILL TN
37317-1162
US

V. Phone/Fax

Practice location:
  • Phone: 423-496-9214
  • Fax: 423-496-7809
Mailing address:
  • Phone: 423-496-9214
  • Fax: 423-496-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD0000026174
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: