=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922330851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLADWIN FAMILY CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2137 W M 61
-----------------------------------------------------
City | GLADWIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48624-8463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-426-9399
-----------------------------------------------------
Fax | 989-246-2257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2137 W M 61
-----------------------------------------------------
City | GLADWIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48624-8463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-426-9399
-----------------------------------------------------
Fax | 989-246-2257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAREK MUSTAPHA EZZEDDINE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 989-426-9399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301080387
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------