Basic Information
| Provider Information | |||||||||
| NPI: | 1538153176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAJJAR | ||||||||
| FirstName: | RIAD | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 STONE ST | ||||||||
| Address2: | STE. 5 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109669556 | ||||||||
| FaxNumber: | 8109664898 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 STONE ST | ||||||||
| Address2: | STE. 5 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109669556 | ||||||||
| FaxNumber: | 8109664898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | RH066725 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 127697 | 05 | MI | MEDICAID |