Healthcare Provider Details

I. General information

NPI: 1548125313
Provider Name (Legal Business Name): MEDICAL HAVEN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 ORCHARD LAKE RD # 605
KEEGO HARBOR MI
48320-9991
US

IV. Provider business mailing address

2851 ORCHARD LAKE RD # 605
KEEGO HARBOR MI
48320-9991
US

V. Phone/Fax

Practice location:
  • Phone: 313-858-0374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD M BALLOUT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 734-410-6829