=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982337358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED ADEL MOHAMMED CCP, LP, MPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2022
-----------------------------------------------------
Last Update Date | 07/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 959 S INDIANA AVE
-----------------------------------------------------
City | SELLERSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47172-1639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-234-3266
-----------------------------------------------------
Fax | 877-455-1021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2773
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47131-2773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-736-2211
-----------------------------------------------------
Fax | 877-455-1021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | 214
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | FPF02000199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | PRF000451
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | 2019027175
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | 214000415
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------