Provider Demographics
NPI:1447217732
Name:GENESEE PEDIATRICS PC
Entity Type:Organization
Organization Name:GENESEE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-720-1510
Mailing Address - Street 1:G5119 W BRISTOL ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-720-1510
Mailing Address - Fax:810-720-1726
Practice Address - Street 1:G5119 W BRISTOL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-720-1510
Practice Address - Fax:810-720-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067983208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4215497Medicaid
H26536Medicare UPIN
MION19180Medicare ID - Type Unspecified