Provider Demographics
NPI:1962876722
Name:MOHAMEDABDH, MOHAMED MOHAMOUD
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:MOHAMOUD
Last Name:MOHAMEDABDH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28561
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55128-0561
Mailing Address - Country:US
Mailing Address - Phone:507-573-1608
Mailing Address - Fax:
Practice Address - Street 1:912 E 24TH ST
Practice Address - Street 2:STE B215
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3869
Practice Address - Country:US
Practice Address - Phone:507-573-1608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300595677343900000X
MN1566943251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251E00000XAgenciesHome Health