Provider Demographics
NPI:1598791931
Name:YAISH, AMJAD M (DO)
Entity Type:Individual
Prefix:DR
First Name:AMJAD
Middle Name:M
Last Name:YAISH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21620 HARRINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2319
Mailing Address - Country:US
Mailing Address - Phone:586-469-8300
Mailing Address - Fax:
Practice Address - Street 1:21620 HARRINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-2319
Practice Address - Country:US
Practice Address - Phone:586-469-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013550207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4422008Medicaid
MI4422008Medicaid
MION59910Medicare ID - Type Unspecified