Provider Demographics
NPI:1629140447
Name:HALLAK, KASSEM MAHMOUD (MD MS)
Entity Type:Individual
Prefix:DR
First Name:KASSEM
Middle Name:MAHMOUD
Last Name:HALLAK
Suffix:
Gender:M
Credentials:MD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813
Mailing Address - Country:US
Mailing Address - Phone:517-543-7800
Mailing Address - Fax:517-543-7900
Practice Address - Street 1:616 MEIJER ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813
Practice Address - Country:US
Practice Address - Phone:517-543-7800
Practice Address - Fax:517-543-7900
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104863352Medicaid
P25920002Medicare ID - Type Unspecified
G18780Medicare UPIN