Basic Information
| Provider Information | |||||||||
| NPI: | 1043884257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KADHIM | ||||||||
| FirstName: | WASSAN | ||||||||
| MiddleName: | JAWAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | GME OFFICE - UHC 9C 4201 ST. ANTOINE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST # 6A6B | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.