Healthcare Provider Details

I. General information

NPI: 1679704100
Provider Name (Legal Business Name): DANY MAMOU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 E CHICAGO RD
STURGIS MI
49091-8524
US

IV. Provider business mailing address

15 S MCHENRY RD
BUFFALO GROVE IL
60089-6705
US

V. Phone/Fax

Practice location:
  • Phone: 269-659-6747
  • Fax: 269-659-6746
Mailing address:
  • Phone: 847-459-6100
  • Fax: 847-541-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036142021
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301100135
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: