Provider Demographics
NPI:1346407525
Name:OSMAN, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:OSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD STE 707
Mailing Address - Street 2:BEAUMONT CHILDREN'S HOSPITAL PEDIATRIC GASTROENTEROLOGY
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-0487
Mailing Address - Fax:248-551-3696
Practice Address - Street 1:3535 W 13 MILE RD STE 707
Practice Address - Street 2:BEAUMONT CHILDREN'S HOSPITAL PEDIATRIC GASTROENTEROLOGY
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0487
Practice Address - Fax:248-551-3696
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI43011040352080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA06243Medicaid