Healthcare Provider Details

I. General information

NPI: 1649341876
Provider Name (Legal Business Name): JACKSON ORTHOPAEDIC CARE & SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SUMMIT AVE SUITE A
JACKSON MI
49201-2464
US

IV. Provider business mailing address

3816 MOMENTUM PL
CHICAGO IL
60689-5338
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-1495
  • Fax: 517-784-1051
Mailing address:
  • Phone: 517-784-1495
  • Fax: 517-784-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101010754
License Number StateMI

VIII. Authorized Official

Name: DR. KHAWAJA HAROUN IKRAM
Title or Position: PRESIDENT
Credential: D.O.
Phone: 517-784-1495