Provider Demographics
NPI:1558436022
Name:AL-AZEM, MOHAMED WADAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:WADAH
Last Name:AL-AZEM
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 1:168 S HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-2040
Mailing Address - Country:US
Mailing Address - Phone:517-437-5149
Mailing Address - Fax:
Practice Address - Street 1:168 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-2040
Practice Address - Country:US
Practice Address - Phone:517-437-5149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010360702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00034317OtherRAILROAD MEDICARE
MI1620026OtherPHYSICIANS HEALTH PLAN
MI4481395Medicaid
MIB51129Medicare UPIN
MI0N463620002Medicare ID - Type Unspecified