Basic Information
| Provider Information | |||||||||
| NPI: | 1154621563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GHULAM QADIR MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 PARKLANE BLVD | ||||||||
| Address2: | SUITE 695 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
| FaxNumber: | 3132718353 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 PARKLANE BLVD | ||||||||
| Address2: | SUITE 695 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
| FaxNumber: | 3132718353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | QADIR | ||||||||
| AuthorizedOfficialFirstName: | GHULAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3132718170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301040442 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 102100490 | 05 | MI | MEDICAID |