Healthcare Provider Details

I. General information

NPI: 1437644127
Provider Name (Legal Business Name): MARYAM SOMO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 N STATE RD STE 101
OWOSSO MI
48867-9075
US

IV. Provider business mailing address

239 N STATE RD STE 101
OWOSSO MI
48867-9075
US

V. Phone/Fax

Practice location:
  • Phone: 989-743-3415
  • Fax: 989-743-6180
Mailing address:
  • Phone: 989-743-3415
  • Fax: 989-743-6180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301115221
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301504106
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: