Provider Demographics
NPI:1023105418
Name:OWOSSO MEDICAL GROUP, PC
Entity type:Organization
Organization Name:OWOSSO MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AZMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-723-8666
Mailing Address - Street 1:200 HEALTH PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867
Mailing Address - Country:US
Mailing Address - Phone:989-723-8666
Mailing Address - Fax:989-729-4983
Practice Address - Street 1:200 HEALTH PARK DRIVE
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867
Practice Address - Country:US
Practice Address - Phone:989-723-8666
Practice Address - Fax:989-729-4983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G810130OtherBLUE CROSS
MI700G810130OtherBLUE CROSS