Provider Demographics
NPI:1154382919
Name:AL-JARRAH, MOHAMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:
Last Name:AL-JARRAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5533 CRISPIN WAY RD
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-3407
Mailing Address - Country:US
Mailing Address - Phone:313-717-8932
Mailing Address - Fax:
Practice Address - Street 1:15830 FORT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1367
Practice Address - Country:US
Practice Address - Phone:734-282-5444
Practice Address - Fax:734-282-4899
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMA057471174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3503774Medicaid
MI4627560Medicaid
MI3503774Medicaid
MI4627560Medicaid
MI0N94270Medicare PIN