MEDICARE: MOHAMMAD MOFREH S ALTALEB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	D0088616	MD

General Provider Information

NPI Number	:	1134767643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMAD MOFREH S ALTALEB

Provider Business Mailing Address
First Line	:	414 LIGHT STREET
Second Line	:	APT 2702
City	:	BALTIMORE
State	:	MD
Zip	:	21202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 NORTH CAROLINE STREET / RM 5223
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21287-0882
Country	:	US
Telephone Number	:	410-955-3376
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	12/16/2019

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