Basic Information
Provider Information | |||||||||
NPI: | 1821130980 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENESEE PEDIATRICS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANAR HAMMOUD, M.D., P.C. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5067 W BRISTOL RD | ||||||||
Address2: | SUITE J | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485072924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107201510 | ||||||||
FaxNumber: | 8107201726 | ||||||||
Practice Location | |||||||||
Address1: | 5067 W BRISTOL RD | ||||||||
Address2: | SUITE J | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485072924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107201510 | ||||||||
FaxNumber: | 8107201726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMMOUD | ||||||||
AuthorizedOfficialFirstName: | MANAR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8107201510 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
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 | 3502505342 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0988606 | 01 | MI | HEALTH PLUS | OTHER |