Provider Demographics
NPI:1114143914
Name:FORDSON MEDICAL GROUP PC
Entity Type:Organization
Organization Name:FORDSON MEDICAL GROUP PC
Other - Org Name:WARREN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALAHUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-558-9869
Mailing Address - Street 1:16921 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3504
Mailing Address - Country:US
Mailing Address - Phone:313-558-9869
Mailing Address - Fax:
Practice Address - Street 1:16921 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3504
Practice Address - Country:US
Practice Address - Phone:313-558-9869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI037730207RI0011X
MI4057742084N0400X
MI0622482084N0400X
MI062441208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG37737Medicare UPIN
MIF32674Medicare UPIN
MIB46529Medicare UPIN
MIH14795Medicare UPIN