Healthcare Provider Details

I. General information

NPI: 1598968158
Provider Name (Legal Business Name): AHMAD MOHAMAD CHARAF EDDINE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST DETROIT MEDICAL CENTER- CHILDREN'S OF MICHIGAN
DETROIT MI
48201-2119
US

IV. Provider business mailing address

1880 PELICAN CT
TROY MI
48084-1432
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-5301
  • Fax:
Mailing address:
  • Phone: 601-519-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301095722
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301095722
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: