Basic Information
| Provider Information | |||||||||
| NPI: | 1861485831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KADRI | ||||||||
| FirstName: | ADEBAMBO | ||||||||
| MiddleName: | MUSTAPHA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KADRI | ||||||||
| OtherFirstName: | MUSTAPHA | ||||||||
| OtherMiddleName: | ADEBAMBO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897543000 | ||||||||
| FaxNumber: | 9897543006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897543000 | ||||||||
| FaxNumber: | 9897543006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 4301105600 | MI | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 02497661 | 05 | NY | MEDICAID |