Provider Demographics
NPI:1790093540
Name:MALIK, FOUAD (PA-C)
Entity Type:Individual
Prefix:
First Name:FOUAD
Middle Name:
Last Name:MALIK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3531
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:
Practice Address - Street 1:4615 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2610
Practice Address - Country:US
Practice Address - Phone:989-631-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5560044OtherBCBS GROUP
MI0E66019087Medicare PIN
MI0P43930Medicare PIN
MI5560044OtherBCBS GROUP
MI0E66019Medicare PIN