Healthcare Provider Details

I. General information

NPI: 1578855847
Provider Name (Legal Business Name): ABDULLAH ADNAN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE
JACKSON MI
49201-1852
US

IV. Provider business mailing address

1201 E MICHIGAN AVE
JACKSON MI
49201-1852
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-1386
  • Fax: 517-205-7525
Mailing address:
  • Phone: 847-962-1386
  • Fax: 517-205-7525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPENDING
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5101021514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: