Healthcare Provider Details

I. General information

NPI: 1295351500
Provider Name (Legal Business Name): ATHAR GHANNAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 E MICHIGAN AVE STE 100
JACKSON MI
49202-3971
US

IV. Provider business mailing address

3235 E MICHIGAN AVE STE 100
JACKSON MI
49202-3971
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3280
  • Fax: 517-205-1181
Mailing address:
  • Phone: 517-205-3280
  • Fax: 517-205-1181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301509386
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: