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NPI Code Detail

MEDICARE: DR. GEORGE DOMINIC MAMMO MD, MS

MEDICARE: DR. GEORGE DOMINIC MAMMO MD, MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2207Q00000XFamily Medicine Physician4301501687MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14301501687OTHERMIMI STATE LIC

General Provider Information

NPI Number : 1659808053
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. GEORGE DOMINIC MAMMO MD, MS
Provider Business Mailing Address
First Line : PO BOX 3790
Second Line :
City : SOUTHFIELD
State : MI
Zip : 48037-3790
Country : US
Telephone Number : 483-364-0002
Fax Number :
Provider Business Practice Location Address
First Line : 4420 E DAVISON ST
Second Line :
City : DETROIT
State : MI
Zip : 48212-1744
Country : US
Telephone Number : 313-369-1500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2017
Last Update Date : 09/23/2020

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