1902896608 NPI number — DR. ALAA G MANSOUR M.D.

Table of content: DR. ALAA G MANSOUR M.D. (NPI 1902896608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902896608 NPI number — DR. ALAA G MANSOUR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSOUR
Provider First Name:
ALAA
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANSOUR
Provider Other First Name:
ALAA
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1902896608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19011 E 10 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-3984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-443-5580
Provider Business Mailing Address Fax Number:
586-443-5590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19011 E 10 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-3984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-443-5580
Provider Business Practice Location Address Fax Number:
586-443-5580
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  AM078660 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4717292 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: I21667 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1105015892 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00304762 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 12852 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16928 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 139818 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 029259 . This is a "MIDWEST MEDICAID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 149966 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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