Provider Demographics
NPI:1124525597
Name:ABDALLAH, AHMED KASSEM SELIM (MD)
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:KASSEM SELIM
Last Name:ABDALLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 MEDICAL PARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5798
Mailing Address - Country:US
Mailing Address - Phone:865-988-9970
Mailing Address - Fax:865-271-6621
Practice Address - Street 1:689 MEDICAL PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5798
Practice Address - Country:US
Practice Address - Phone:865-988-9970
Practice Address - Fax:865-271-6621
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2025-06-24
Deactivation Date:2018-11-28
Deactivation Code:
Reactivation Date:2018-12-05
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN73872207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ067579Medicaid