Provider Demographics
NPI:1093731382
Name:AL SHAHROURI, MANAR K (MD)
Entity Type:Individual
Prefix:
First Name:MANAR
Middle Name:K
Last Name:AL SHAHROURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MANAR
Other - Middle Name:K
Other - Last Name:ALSHAHROURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3706
Practice Address - Fax:920-433-3582
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48991-20207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34850100Medicaid
H85394Medicare UPIN
WI07125-0339Medicare PIN