Healthcare Provider Details

I. General information

NPI: 1154980134
Provider Name (Legal Business Name): AHMED REZK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29877 TELEGRAPH RD STE 301
SOUTHFIELD MI
48034-7660
US

IV. Provider business mailing address

7634 N CHARLESWORTH ST
DEARBORN HEIGHTS MI
48127-1614
US

V. Phone/Fax

Practice location:
  • Phone: 248-359-2370
  • Fax:
Mailing address:
  • Phone: 248-228-7772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704279530
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: