Provider Demographics
NPI: | 1790435840 |
---|---|
Name: | MOHANAD SUEDE MD PC |
Entity Type: | Organization |
Organization Name: | MOHANAD SUEDE MD PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MOHANAD |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SUEDE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 313-779-0406 |
Mailing Address - Street 1: | 6088 GLEN EAGLES DR |
Mailing Address - Street 2: | |
Mailing Address - City: | WEST BLOOMFIELD |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48323-2212 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 50 N PERRY ST |
Practice Address - Street 2: | |
Practice Address - City: | PONTIAC |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48342-2217 |
Practice Address - Country: | US |
Practice Address - Phone: | 708-586-2080 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-03-23 |
Last Update Date: | 2022-03-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Single Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty |