Healthcare Provider Details

I. General information

NPI: 1083612840
Provider Name (Legal Business Name): MOHAMMAD NURUL AMIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MOHAMMAD NURUL AMIN MD

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2157 ORCHARD LAKE DRIVE
SYLVAN LAKE MI
48320
US

IV. Provider business mailing address

2157 ORCHARD LAKE DRIVE
SYLVAN LAKE MI
48320
US

V. Phone/Fax

Practice location:
  • Phone: 248-857-7878
  • Fax: 248-857-7888
Mailing address:
  • Phone: 248-857-7878
  • Fax: 248-857-7888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA048260
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301048260
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301048260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: