Healthcare Provider Details

I. General information

NPI: 1790093540
Provider Name (Legal Business Name): FOUAD MALIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 EASTMAN AVE
MIDLAND MI
48640-2610
US

IV. Provider business mailing address

12100 DIX TOLEDO RD
SOUTHGATE MI
48195-3531
US

V. Phone/Fax

Practice location:
  • Phone: 989-631-7110
  • Fax:
Mailing address:
  • Phone: 989-892-7722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005743
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: