Basic Information
| Provider Information | |||||||||
| NPI: | 1407943962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | S L HUSAIN HAMZAVI MD PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HAMZAVI DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 43151 DALCOMA DR | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 5866496699 | ||||||||
| Practice Location | |||||||||
| Address1: | 43151 DALCOMA DR | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 5866496699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUSAIN HAMZAVI | ||||||||
| AuthorizedOfficialFirstName: | SYED | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5862868720 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | CB4874 | 01 | MI | RAILROAD MEDICARE | OTHER |