Provider Demographics
NPI:1265763973
Name:HAZEL PARK MEDICAL GROUP PC
Entity type:Organization
Organization Name:HAZEL PARK MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSIB
Authorized Official - Middle Name:
Authorized Official - Last Name:GAPPY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-399-8331
Mailing Address - Street 1:23411 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1404
Mailing Address - Country:US
Mailing Address - Phone:248-399-8331
Mailing Address - Fax:248-399-3912
Practice Address - Street 1:3161 HILTON RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1038
Practice Address - Country:US
Practice Address - Phone:248-399-8331
Practice Address - Fax:248-399-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F38756OtherBCBSM
MIMI2626Medicare PIN
MIG54089Medicare UPIN
MI0F38756OtherBCBSM