1801962691 NPI number — ENAS NAKKASH MD,PC

Table of content: ENAS NAKKASH MD,PC (NPI 1801962691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801962691 NPI number — ENAS NAKKASH MD,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAKKASH
Provider First Name:
ENAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD,PC
Provider Gender Code:
F

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:
1801962691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
22039 JOHNR RD
Provider Business Mailing Address City Name:
HAZEL PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48030-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1899 E WATTLES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-5082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-526-9999
Provider Business Practice Location Address Fax Number:
248-526-9089
Provider Enumeration Date:
11/26/2006

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: 207R00000X , with the licence number:  4301077105 , 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: 4724250 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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