Provider Demographics
NPI:1043694979
Name:JAN MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:JAN MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:I
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-690-7994
Mailing Address - Street 1:43361 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1109
Mailing Address - Country:US
Mailing Address - Phone:586-690-7994
Mailing Address - Fax:586-569-2589
Practice Address - Street 1:43361 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-690-7994
Practice Address - Fax:586-569-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092978207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty