Provider Demographics
NPI:1164620753
Name:RIAD R. HAJJAR MD PC
Entity Type:Organization
Organization Name:RIAD R. HAJJAR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:KLANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-966-9556
Mailing Address - Street 1:1201 STONE ST
Mailing Address - Street 2:STE 5
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3563
Mailing Address - Country:US
Mailing Address - Phone:810-966-9556
Mailing Address - Fax:810-966-4898
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:STE 5
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:810-966-9556
Practice Address - Fax:810-966-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRH066725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D5959OtherPALMETTO GBA-RAILROAD MED
MI207R00000XOtherTAXONOMY CODE
MI4263408Medicaid
MIG59776Medicare UPIN
MI4263408Medicaid
MI207R00000XOtherTAXONOMY CODE