Basic Information
| Provider Information | |||||||||
| NPI: | 1104828201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABDRABBO | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | KHALOUCK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10600 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138539250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10600 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138539250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 4301055436 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 35.143765 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 4744440 | 05 | MI | MEDICAID | 300207909 | 01 | MI | TAX ID | OTHER |