1790788701 NPI number — DR. LAYTH MAOLOOD MD, FAAP

Table of content: MS. KERI ROULA (NPI 1396979373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788701 NPI number — DR. LAYTH MAOLOOD MD, FAAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAOLOOD
Provider First Name:
LAYTH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, FAAP
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:
1790788701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3160 LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48140-9703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-432-3621
Provider Business Mailing Address Fax Number:
866-390-9167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3160 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48140-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-432-3621
Provider Business Practice Location Address Fax Number:
866-390-9167
Provider Enumeration Date:
05/23/2005

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: 207R00000X , with the licence number:  35078595 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 35078595 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 4301068044 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301068044 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104592616 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2230713 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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