Provider Demographics
NPI:1649700857
Name:ADAM, OMERALFAROUG AHMED IBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:OMERALFAROUG
Middle Name:AHMED IBRAHIM
Last Name:ADAM
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 1:4201 SAINT ANTOINE ST STE 2E
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4832
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST STE 2E
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2021-11-30
Deactivation Date:2018-01-25
Deactivation Code:
Reactivation Date:2018-05-18
Provider Licenses
StateLicense IDTaxonomies
MI4301503112207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program