Healthcare Provider Details

I. General information

NPI: 1396314779
Provider Name (Legal Business Name): MAHMOUD H ELBORAII FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S ETON ST
BIRMINGHAM MI
48009-6837
US

IV. Provider business mailing address

251 N ROSE ST STE 200
KALAMAZOO MI
49007-3860
US

V. Phone/Fax

Practice location:
  • Phone: 248-423-3096
  • Fax:
Mailing address:
  • Phone: 866-949-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704334830
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704334830
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: