Basic Information
| Provider Information | |||||||||
| NPI: | 1023014610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHALI | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
| FaxNumber: | 5177809286 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 MONROE STREET | ||||||||
| Address2: | WUITE 301 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301057489 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3479730-10 | 05 | MI | MEDICAID |