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General NPI Number Information
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NPI Number | 1043694979
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Entity Type | Organization
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Legal Business Name | JAN MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 07/09/2015
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Last Update Date | 09/19/2016
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Provider Practice Location Address
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Address Line | 43361 COMMONS DR
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-1109
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Country | US
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Telephone | 586-690-7994
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Fax | 586-569-2589
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Provider Business Mailing Address
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Address Line | 43361 COMMONS DR
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-1109
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Country | US
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Telephone | 586-690-7994
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Fax | 586-569-2589
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Authorized Official
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Title or Position | MEMBER
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Name | DR. FADI I IBRAHIM
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Credential | M.D.
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Telephone | 586-690-7994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301092978
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License Number State | MI
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