Healthcare Provider Details

I. General information

NPI: 1023105418
Provider Name (Legal Business Name): OWOSSO MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH PARK DRIVE
OWOSSO MI
48867
US

IV. Provider business mailing address

200 HEALTH PARK DRIVE
OWOSSO MI
48867
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-8666
  • Fax: 989-729-4983
Mailing address:
  • Phone: 989-723-8666
  • Fax: 989-729-4983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. AZMY A ALLAM
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 989-723-8666