Provider Demographics
NPI:1285816090
Name:WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE
Entity Type:Organization
Organization Name:WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE
Other - Org Name:UNIVERSITY PHYSICIAN GROU
Other - Org Type:Other Name
Authorized Official - Title/Position:DIVISION CHIEF ENDOCRINOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:ABOU-SAMRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:313-745-4008
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:UNIVERSITY HEALTH CENTER - 4H
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4008
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:UNIVERSITY HEALTH CENTER - 4H
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089157282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital