1265400477 NPI number — MUHAMMAD AZRAK

Table of content: MUHAMMAD AZRAK (NPI 1265400477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265400477 NPI number — MUHAMMAD AZRAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AZRAK
Provider First Name:
MUHAMMAD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1265400477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1863
Provider Business Mailing Address Fax Number:
947-522-0307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18100 OAKWOOD BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-438-7880
Provider Business Practice Location Address Fax Number:
313-438-7882
Provider Enumeration Date:
03/14/2006

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: 207RG0100X , with the licence number:  4301069915 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 4301069915 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110F376980 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4234456 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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