Basic Information
Provider Information | |||||||||
NPI: | 1376661991 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MICHIGAN SLEEP CENTER PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 GREENFIELD RD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481264124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139456100 | ||||||||
FaxNumber: | 3139455260 | ||||||||
Practice Location | |||||||||
Address1: | 4700 GREENFIELD RD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481264124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139456100 | ||||||||
FaxNumber: | 3139455260 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 04/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABDULRAZZAK | ||||||||
AuthorizedOfficialFirstName: | MAMDOUH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3139456100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301063026 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.