Provider Demographics
NPI:1184930604
Name:SAHLOL, MARK HAZEM
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HAZEM
Last Name:SAHLOL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MOHAMAD
Other - Middle Name:HAZEM
Other - Last Name:SAHLOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-852-1524
Practice Address - Fax:219-933-2288
Is Sole Proprietor?:No
Enumeration Date:2010-08-21
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152202207R00000X
IL036124446207R00000X
IN01075458A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201292580Medicaid