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General NPI Number Information
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NPI Number | 1588113211
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Entity Type | Organization
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Legal Business Name | BG ANTAR, LLC
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Dates
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Enumeration Date | 09/22/2016
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 11716 DETROIT AVE
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City | LAKEWOOD
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State | OH
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Zip | 44107-3002
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Country | US
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Telephone | 440-315-1489
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 770800
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City | LAKEWOOD
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State | OH
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Zip | 44107-0037
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Country | US
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Telephone | 440-315-1489
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Fax | 440-363-5875
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Authorized Official
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Title or Position | OWNER
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Name | MOHAMMED FREDDIE AHMAD
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Credential | MD
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Telephone | 440-315-1489
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35124466
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License Number State | OH
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