Provider Demographics
NPI:1982912002
Name:MOSTAFA S SADRY MD PC
Entity Type:Organization
Organization Name:MOSTAFA S SADRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSTAFA
Authorized Official - Middle Name:SEIED
Authorized Official - Last Name:SADRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-985-4100
Mailing Address - Street 1:2603 ELECTRIC AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6588
Mailing Address - Country:US
Mailing Address - Phone:810-985-4100
Mailing Address - Fax:810-985-8244
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6588
Practice Address - Country:US
Practice Address - Phone:810-985-4100
Practice Address - Fax:810-985-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMS0440762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2118850Medicaid
MI0740030Medicare PIN
MI0001398Medicare UPIN