1366091613 NPI number — MAHMOUD MUSTAFA MUSA M.D.

Table of content: MAHMOUD MUSTAFA MUSA M.D. (NPI 1366091613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366091613 NPI number — MAHMOUD MUSTAFA MUSA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSA
Provider First Name:
MAHMOUD
Provider Middle Name:
MUSTAFA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366091613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4160 JOHN R ST.
Provider Second Line Business Mailing Address:
DIVISION OF NEPHROLOGY/HARPER PROFESSIONAL OFFICE BUILD
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-745-7145
Provider Business Mailing Address Fax Number:
313-745-8041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 JOHN R ST.
Provider Second Line Business Practice Location Address:
DIVISION OF NEPHROLOGY/HARPER PROFESSIONAL OFFICE BUILD
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-7145
Provider Business Practice Location Address Fax Number:
313-745-8041
Provider Enumeration Date:
09/10/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)