Provider Demographics
NPI:1245317072
Name:KAZEM, ESAM A (MD)
Entity type:Individual
Prefix:
First Name:ESAM
Middle Name:A
Last Name:KAZEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:44405 WOODWARD H-24
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48053
Mailing Address - Country:US
Mailing Address - Phone:248-858-3526
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:44405 WOODWARD H-24
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48053
Practice Address - Country:US
Practice Address - Phone:248-858-3526
Practice Address - Fax:248-858-3532
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010668792080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
EK066879OtherCHAMPUS-CHAMPUS
EK066879OtherCOMMERCIAL-COMMERCIAL NUMBER
G23245Medicare UPIN