Basic Information
| Provider Information | |||||||||
| NPI: | 1386660983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25404 GODDARD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132920140 | ||||||||
| FaxNumber: | 3132923542 | ||||||||
| Practice Location | |||||||||
| Address1: | 25404 GODDARD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132920140 | ||||||||
| FaxNumber: | 3132923542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | SYED | ||||||||
| AuthorizedOfficialFirstName: | NAJAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3132920140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0P29180 | 01 | MI | MEDICARE | OTHER | 4331496 | 05 | MI | MEDICAID |