Provider Demographics
NPI:1205834470
Name:MADOUN, MANAF (MD)
Entity Type:Individual
Prefix:
First Name:MANAF
Middle Name:
Last Name:MADOUN
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 1:28925 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1272
Mailing Address - Country:US
Mailing Address - Phone:586-552-0269
Mailing Address - Fax:586-279-0833
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:586-552-0269
Practice Address - Fax:586-279-0833
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073570208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI48429566Medicaid
MIMM073570OtherBCBSM
MIMM073570OtherBCBSM
MIP28070028Medicare ID - Type Unspecified