Basic Information
| Provider Information | |||||||||
| NPI: | 1538260005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EL-JACK | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157354200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3003 UNIVERSITY DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157328491 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 44615 | WI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 34272500 | 05 | WI | MEDICAID | 104434930 | 05 | MI | MEDICAID | BE7933953 | 01 | DEA NUMBER | OTHER | 1538260005 | 05 | WI | MEDICAID | 1538260005 | 05 | MI | MEDICAID |