Basic Information
| Provider Information | |||||||||
| NPI: | 1568580272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUHAMMED R MIRZA MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 W CEDAR STREET | ||||||||
| Address2: | PO BOX 430 | ||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898463555 | ||||||||
| FaxNumber: | 9898463546 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W CEDAR STREET | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898463555 | ||||||||
| FaxNumber: | 9898463546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIRZA | ||||||||
| AuthorizedOfficialFirstName: | MUHAMMED | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9898463555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301064585 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301064585 | 01 | MI | LICENSE NUMBER | OTHER | 1437156015 | 01 | MI | NPI INDIVIDUAL | OTHER | 0100647012 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 4224665 | 05 | MI | MEDICAID | 64R01184 | 01 | MI | HEALTH PLUS ID | OTHER |