Basic Information
| Provider Information | |||||||||
| NPI: | 1447217732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESEE PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | G5119 W BRISTOL ROAD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107201510 | ||||||||
| FaxNumber: | 8107201726 | ||||||||
| Practice Location | |||||||||
| Address1: | G5119 W BRISTOL ROAD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107201510 | ||||||||
| FaxNumber: | 8107201726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAMMOUD | ||||||||
| AuthorizedOfficialFirstName: | MANAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8107201510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301067983 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4215497 | 05 | MI | MEDICAID |