Provider Demographics
NPI:1528026424
Name:GHANEM, AMMAR (MD)
Entity Type:Individual
Prefix:
First Name:AMMAR
Middle Name:
Last Name:GHANEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BARCLAY CIR STE 205
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5821
Mailing Address - Country:US
Mailing Address - Phone:248-651-6430
Mailing Address - Fax:260-416-5897
Practice Address - Street 1:75 BARCLAY CIR STE 205
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5821
Practice Address - Country:US
Practice Address - Phone:260-416-5892
Practice Address - Fax:260-416-5897
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085090207R00000X, 207RC0200X, 207RP1001X
IN01067395207RP1001X, 207RC0200X, 207RS0012X
MI4301111042207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000658707OtherANTHEM
IN200982500Medicaid
IN7424707OtherAETNA
MI1346790896Medicaid
OH2626420Medicaid
H99405Medicare UPIN
INM400018715Medicare PIN