Healthcare Provider Details

I. General information

NPI: 1114086857
Provider Name (Legal Business Name): MOHAMED SIDDIQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 TELEGRAPH
REDFORD MI
48239
US

IV. Provider business mailing address

6286 TIMBERWOOD
WEST BLOOMFIELD MI
48322
US

V. Phone/Fax

Practice location:
  • Phone: 313-450-4500
  • Fax: 313-450-4514
Mailing address:
  • Phone: 313-661-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301047009
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301047009
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: