Basic Information
| Provider Information | |||||||||
| NPI: | 1831403401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAMDOUH ABDULRAZZAK MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 250341 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480250341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 GREENFIELD RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481201802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2010 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | ABDULRAZZAK | ||||||||
| AuthorizedOfficialFirstName: | MAMDOUH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3135633332 | ||||||||
| 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 | 2084N0400X | 4301063026 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | MI3232 | 01 | MI | MEDICARE | OTHER |