Provider Demographics
NPI:1699777995
Name:HASHEM, MUSTAFA A (MD)
Entity type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:A
Last Name:HASHEM
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 1:15150 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1302
Mailing Address - Country:US
Mailing Address - Phone:734-282-4800
Mailing Address - Fax:734-282-5039
Practice Address - Street 1:15150 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1302
Practice Address - Country:US
Practice Address - Phone:734-282-4800
Practice Address - Fax:734-282-9302
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301607758207R00000X
MI4301067758207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00339351OtherRR MEDICARE
MIP34850001OtherMEDICARE IND PIN #
MI11058553OtherCAQH
MI4301067758OtherCDS #
MIH75500OtherHAP
MI1699777995OtherBCBSM IND NPI #
MI0826155OtherBLUE CARE NETWORK
MI4301067758OtherSTATE LICENSE #
MI4893450Medicaid
MI4301067758OtherCDS #