Provider Demographics
NPI:1629102934
Name:DEARBORN GASTROENTEROLOGY
Entity Type:Organization
Organization Name:DEARBORN GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-768-1225
Mailing Address - Street 1:23601 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1227
Mailing Address - Country:US
Mailing Address - Phone:517-768-1225
Mailing Address - Fax:
Practice Address - Street 1:23601 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1227
Practice Address - Country:US
Practice Address - Phone:517-768-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P26190Medicare ID - Type Unspecified