1578519286 NPI number — DR. MOHAMMAD N AL SHROOF M.D.

Table of content: DR. MOHAMMAD N AL SHROOF M.D. (NPI 1578519286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578519286 NPI number — DR. MOHAMMAD N AL SHROOF M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AL SHROOF
Provider First Name:
MOHAMMAD
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578519286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2054 WATSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31093-3634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-918-0770
Provider Business Mailing Address Fax Number:
478-918-0771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2054 WATSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31093-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-918-0770
Provider Business Practice Location Address Fax Number:
478-918-0771
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  045158 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000807155I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000807155R , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 614236400 . This is a "DEPT OF LABOR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1578519286 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 468916 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000807155AB , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511I110627 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000807155AC , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 867194728A . This is a "GBHC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 110237442 . This is a "MEDICARE RAILROAD#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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