Provider Demographics
NPI:1538778303
Name:FATEMA OMRAN MDPC PLLC
Entity type:Organization
Organization Name:FATEMA OMRAN MDPC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FATEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OMRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-602-5940
Mailing Address - Street 1:268 RIDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6255 INKSTER RD STE 204
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2538
Practice Address - Country:US
Practice Address - Phone:248-602-5940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063-71-0523Medicaid