MEDICARE: MEDICAL HAVEN PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1548125313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL HAVEN PLLC

Provider Business Mailing Address
First Line	:	2851 ORCHARD LAKE RD # 605
Second Line	:
City	:	KEEGO HARBOR
State	:	MI
Zip	:	48320-9991
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2851 ORCHARD LAKE RD # 605
Second Line	:
City	:	KEEGO HARBOR
State	:	MI
Zip	:	48320-9991
Country	:	US
Telephone Number	:	313-858-0374
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MOHAMMAD M BALLOUT
Credential	:	MD
Telephone Number	:	313-858-0374

Provider Enumeration Date	:	12/23/2025
Last Update Date	:	12/23/2025

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