Provider Demographics
NPI:1083612840
Name:AMIN, MOHAMMAD NURUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:NURUL
Last Name:AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:NURUL
Other - Last Name:AMIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2157 ORCHARD LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SYLVAN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48320
Mailing Address - Country:US
Mailing Address - Phone:248-857-7878
Mailing Address - Fax:248-857-7888
Practice Address - Street 1:2157 ORCHARD LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:SYLVAN LAKE
Practice Address - State:MI
Practice Address - Zip Code:48320
Practice Address - Country:US
Practice Address - Phone:248-857-7878
Practice Address - Fax:248-857-7888
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMA048260208000000X
MI4301048260208D00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3506305691OtherBCBS IND
MI1759477Medicaid
MI1083612840Medicaid
MIMI4744001Medicare PIN
MI3506305691OtherBCBS IND
MIA79285Medicare UPIN
MIMI3292003Medicare PIN