1396728507 NPI number — DR. FEROZE A MOMIN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396728507 NPI number — DR. FEROZE A MOMIN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MOMIN

Provider First Name:

FEROZE

Provider Middle Name:

A

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1396728507

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/29/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

13530 MICHIGAN AVE

Provider Second Line Business Mailing Address:

STE 242

Provider Business Mailing Address City Name:

DEARBORN

Provider Business Mailing Address State Name:

MI

Provider Business Mailing Address Postal Code:

48126-3575

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

313-388-6299

Provider Business Mailing Address Fax Number:

313-388-6328

Provider First Line Business Practice Location Address:

2021 MONROE ST STE 203

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DEARBORN

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48124-2926

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

313-388-6299

Provider Business Practice Location Address Fax Number:

313-388-6328

Provider Enumeration Date:

11/22/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RH0003X , with the licence number:  4301051771 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 900003803 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 01004356 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 014995 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 1105020291 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: F25010 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 431518910 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 481780510 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: CH9161 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 110E002110 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 124278 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 1396728507 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 48121 . This is a "OMNICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".