Basic Information
| Provider Information | |||||||||
| NPI: | 1235664996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QAQISH | ||||||||
| FirstName: | JIRIES | ||||||||
| MiddleName: | AZMI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44405 WOODWARD AVE. | ||||||||
| Address2: | ST. JOSEPH MERCY - OAKLAND | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586233 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD AVE. | ||||||||
| Address2: | ST. JOSEPH MERCY - OAKLAND | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/06/2017 | ||||||||
| NPIReactivationDate: | 12/28/2017 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 4301501438 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.