Basic Information
| Provider Information | |||||||||
| NPI: | 1245317072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAZEM | ||||||||
| FirstName: | ESAM | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 44405 WOODWARD H-24 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583526 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 44405 WOODWARD H-24 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488583526 | ||||||||
| FaxNumber: | 2488583532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 4301066879 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | EK066879 | 01 | CHAMPUS-CHAMPUS | OTHER | EK066879 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER |