Provider Demographics
NPI:1205000205
Name:ELIAS G GENNAOUI M.D. PC
Entity Type:Organization
Organization Name:ELIAS G GENNAOUI M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:GENNAOUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-386-3930
Mailing Address - Street 1:14825 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2642
Mailing Address - Country:US
Mailing Address - Phone:313-386-3930
Mailing Address - Fax:313-386-0962
Practice Address - Street 1:14825 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2642
Practice Address - Country:US
Practice Address - Phone:313-386-3930
Practice Address - Fax:313-386-0962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEG037248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3442150Medicaid
MI3442150Medicaid