Basic Information
| Provider Information | |||||||||
| NPI: | 1851779797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHATILA | ||||||||
| FirstName: | MOUHAMED | ||||||||
| MiddleName: | OSMAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11885 E 12 MILE RD STE 300A | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865826630 | ||||||||
| FaxNumber: | 5865826631 | ||||||||
| Practice Location | |||||||||
| Address1: | 11885 E 12 MILE RD STE 300A | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865826630 | ||||||||
| FaxNumber: | 5865826631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2015 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101021657 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 5101021657 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.