Basic Information
Provider Information | |||||||||
NPI: | 1760794903 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALEH | ||||||||
FirstName: | MOHAMMAD | ||||||||
MiddleName: | YASIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1447 N HARRISON ST | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486024727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895832794 | ||||||||
FaxNumber: | 9895832829 | ||||||||
Practice Location | |||||||||
Address1: | 1447 N HARRISON ST | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486024727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895832422 | ||||||||
FaxNumber: | 9895834287 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2010 | ||||||||
LastUpdateDate: | 10/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301096637 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1760794903 | 05 | MI |   | MEDICAID |