Provider Demographics
NPI:1043410145
Name:ABDALLAH, WISSAM MOHAMAD (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:MOHAMAD
Last Name:ABDALLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 BRADFORD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6427
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:616-885-5020
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090289207RC0000X, 207RC0000X, 390200000X
TN46782208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100196160Medicaid
TN103I115489Medicare PIN
TN4326129OtherBCBST
TN1528041Medicaid