=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083628119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABDEL SALAM AHMED MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 12/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 BEACHLEY ST
-----------------------------------------------------
City | MEYERSDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15552-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-634-5935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 OAK ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-417-0648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 044432
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD438689
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------