=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467705798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAREK LOTFY IBRAHIM MOHAMED MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2012
-----------------------------------------------------
Last Update Date | 10/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 E MICHIGAN AVE SPARROW HOSPITAL, NEONATOLOGY UNIT, 3RD FLOOR
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-364-2468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 SERVICE RD # A109F
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48824-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-884-2976
-----------------------------------------------------
Fax | 517-432-3928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 4301099872
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------