Basic Information
| Provider Information | |||||||||
| NPI: | 1215145420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUSTAFA | ||||||||
| FirstName: | HOSSAM ELDIN | ||||||||
| MiddleName: | IMAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1447 N HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895834700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 COOPER AVE STE 4100 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895834700 | ||||||||
| FaxNumber: | 9895837173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2007 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 35.089607 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 4301086127 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 2760043 | 05 | OH | MEDICAID |