Provider Demographics
NPI:1508287632
Name:MOHAMMAD GHAEMI, M. D.
Entity Type:Organization
Organization Name:MOHAMMAD GHAEMI, M. D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-528-3720
Mailing Address - Street 1:4792 ROCHESTER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4989
Mailing Address - Country:US
Mailing Address - Phone:248-528-3720
Mailing Address - Fax:248-528-3721
Practice Address - Street 1:4792 ROCHESTER RD
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4989
Practice Address - Country:US
Practice Address - Phone:248-528-3720
Practice Address - Fax:248-528-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG031276261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2121856Medicaid