Healthcare Provider Details

I. General information

NPI: 1417407032
Provider Name (Legal Business Name): PREMIER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22318 FORD RD
DEARBORN HEIGHTS MI
48127-2421
US

IV. Provider business mailing address

22318 FORD RD
DEARBORN HEIGHTS MI
48127-2421
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-2788
  • Fax: 313-278-8215
Mailing address:
  • Phone: 313-278-2788
  • Fax: 313-278-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101016795
License Number StateMI

VIII. Authorized Official

Name: DR. MAZEN NASEEB HAMAMEH
Title or Position: MEMBER PHYSICIAN
Credential: DO
Phone: 313-278-2788