Healthcare Provider Details

I. General information

NPI: 1871567651
Provider Name (Legal Business Name): FAWAZ AL-EJEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24623 GREENFIELD RD
SOUTHFIELD MI
48075-3058
US

IV. Provider business mailing address

PO BOX 77000 DEPARTMENT 771267
DETROIT MI
48277-1267
US

V. Phone/Fax

Practice location:
  • Phone: 248-290-3111
  • Fax: 248-290-3100
Mailing address:
  • Phone: 248-290-3111
  • Fax: 248-290-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301056772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: