NPIMap

Individual provider Active NPI

Imtiaz Mohamed, MD

  • Gastroenterology Physician
  • Hayward, WI
National Provider Identifier
1396796884
Registry record updated Jun 12, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gastroenterology PhysicianTaxonomy code 207RG0100X
License
56386 Issued in MN
Practice address
11040 N State Road 77
Hayward, WI 54843-3606
Phone
(715) 934-4321
NPI assigned
May 12, 2006
Last updated
Jun 12, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Gastroenterology Physician 207RG0100X 41063 WI
Gastroenterology Physician 207RG0100X 56386 MN Primary

Addresses

Primary practice location

11040 N State Road 77
Hayward, WI 54843-3606

Mailing address

11040 N State Road 77
Hayward, WI 54843-3606
Phone (715) 934-4321

Other identifiers 4

IdentifierTypeStateIssuer
1396796884MedicaidMI
1396796884MedicaidWI
1396796884MedicaidMN
32584300MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI, MN3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20060404000760 WI Practitioner - GastroenterologyPractitioner - Internal Medicine 9739197534 Reassigns benefits to 1 organization
I20200930000240 MN Practitioner - Emergency Medicine 9739197534 Reassigns benefits to 2 organizations
I20260505004327 WI Practitioner - Emergency Medicine 9739197534 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Other, 1989
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

1615 Maple LN
Ashland, WI 54806-3626

1615 Maple LN
Ashland, WI 54806-3689

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Lake View Memorial Hospital, Inc Gastroenterology Current Accepting new patients
Lake View Clinic CurrentSince Sep 14, 2020 Accepting new patients
Medical Services, Inc Current Accepting new patients
Lake View Memorial Hospital, Inc. CurrentSince Sep 14, 2020 Accepting new patients
Ri-Lee Medical Staffing, Inc. PastSince Aug 1, 2005 Accepting new patients

Locations

29980 Network Pl
Chicago, IL 60673

325 11th Ave
Two Harbors, MN 55616
Phone (218) 834-5520

1615 Maple Ln
Ashland, WI 54806
Phone (715) 682-4563

11040 N State Road 77
Hayward, WI 54843
Phone (715) 934-4244

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1591920000000",
    "number": "1396796884",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11040 N STATE ROAD 77",
            "city": "HAYWARD",
            "state": "WI",
            "postal_code": "548433606",
            "telephone_number": "715-934-4321"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11040 N STATE ROAD 77",
            "city": "HAYWARD",
            "state": "WI",
            "postal_code": "548433606",
            "telephone_number": "715-934-4321"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MOHAMED",
        "first_name": "IMTIAZ",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-12",
        "last_updated": "2020-06-12",
        "certification_date": "2020-06-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "WI",
            "license": "41063",
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "MN",
            "license": "56386",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396796884",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396796884",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396796884",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32584300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hayward, WI

Sources for this page

Verify at the official NPI Registry.