Healthcare Provider Details

I. General information

NPI: 1245246446
Provider Name (Legal Business Name): WASEEM ULLAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE IMAGING SERVICES
JACKSON MI
49201-1753
US

IV. Provider business mailing address

2800 SPRING ARBOR RD STE 102 PO BOX 905
JACKSON MI
49203-3895
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-2612
  • Fax: 571-783-5991
Mailing address:
  • Phone: 517-783-2612
  • Fax: 517-783-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301083777
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: