Healthcare Provider Details

I. General information

NPI: 1083174577
Provider Name (Legal Business Name): KHASHAYAR AHMADMEHRABI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 JACKSON RD STE 320
ANN ARBOR MI
48103-1890
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR STE J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-426-1931
  • Fax: 734-426-9021
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301512155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: