Provider Demographics
NPI:1609087626
Name:JACKSON ORTHOPAEDIC CARE & SURGERY, P.C.
Entity Type:Organization
Organization Name:JACKSON ORTHOPAEDIC CARE & SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAWAJA
Authorized Official - Middle Name:HAROUN
Authorized Official - Last Name:IKRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-784-1495
Mailing Address - Street 1:3816 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5338
Mailing Address - Country:US
Mailing Address - Phone:517-784-1495
Mailing Address - Fax:517-784-1051
Practice Address - Street 1:200 SUMMIT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2464
Practice Address - Country:US
Practice Address - Phone:517-784-1495
Practice Address - Fax:517-784-1051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON ORTHOPAEDIC CARE & SURGERY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010754332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C811480OtherBCBS SUPPLIER PIN
MI540C811480OtherBCBS SUPPLIER PIN
MI5466290001Medicare NSC