Healthcare Provider Details

I. General information

NPI: 1023014610
Provider Name (Legal Business Name): MOHAMMAD GHALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/03/2023
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 MONROE STREET WUITE 301
SYLVANIA OH
43560-2737
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-2121
  • Fax: 419-479-6017
Mailing address:
  • Phone: 517-748-5500
  • Fax: 517-780-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301057489
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: