Provider Demographics
NPI:1194618694
Name:IDAHOR, COURAGE OSAMUDIAMEN
Entity type:Individual
Prefix:
First Name:COURAGE
Middle Name:OSAMUDIAMEN
Last Name:IDAHOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 W. NINE MILE ROAD SOUTHFIELD MI 48075 HENRY FORD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-849-5664
Mailing Address - Fax:248-849-5323
Practice Address - Street 1:16001 W. NINE MILE ROAD SOUTHFIELD MI 48075 HENRY FORD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-849-5664
Practice Address - Fax:248-849-5323
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351054178207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine