=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720368897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE SOURCE MEDIC-CLINIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2011
-----------------------------------------------------
Last Update Date | 08/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2802 GARTH RD SUITE 211
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-839-7244
-----------------------------------------------------
Fax | 281-839-7374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2802 GARTH RD SUITE 211
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-839-7244
-----------------------------------------------------
Fax | 281-839-7374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. MOHAMMAD AHMED
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 281-839-7244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N7047
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------