Provider Demographics
NPI:1285696682
Name:GEORGE MOHAMEDALLY DO PC
Entity type:Organization
Organization Name:GEORGE MOHAMEDALLY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:STALIN
Authorized Official - Last Name:MOHAMEDALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-631-6373
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:387 NORTH STATE
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463
Practice Address - Country:US
Practice Address - Phone:810-631-4060
Practice Address - Fax:810-631-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1304422Medicaid
MI1304422Medicaid
5253924Medicare ID - Type Unspecified