1932195203 NPI number — DR. ABDUL-BADI ABOU-SAMRA M.D., PH.D.

Table of content: DR. ABDUL-BADI ABOU-SAMRA M.D., PH.D. (NPI 1932195203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932195203 NPI number — DR. ABDUL-BADI ABOU-SAMRA M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABOU-SAMRA
Provider First Name:
ABDUL-BADI
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMRA
Provider Other First Name:
ABDUL
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D., PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932195203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201-2061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 JOHN R ST
Provider Second Line Business Practice Location Address:
SUITE 917
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-4525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2005

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: 207RE0101X , with the licence number:  4301089157 , 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: 724182 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 8327117-001 . This is a "CIGNA PAL #'S" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3071405 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 58956 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5904607 . This is a "AETNA:" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: E80629042MGH . This is a "HPHC- PBO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: UNITED-PBO . This is a "3304179" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: E80629MGH . This is a "HPHC-ACD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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