Provider Demographics
NPI:1326077058
Name:MANSOUR, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MANSOUR
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 1:1700 SPRING HILL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1416
Mailing Address - Country:US
Mailing Address - Phone:251-435-1200
Mailing Address - Fax:251-435-6357
Practice Address - Street 1:1700 SPRING HILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1416
Practice Address - Country:US
Practice Address - Phone:251-435-1200
Practice Address - Fax:251-435-6357
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10715207RC0000X
AL44178207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
134987001OtherMEDICAID OF ARKANSAS
MS00118990Medicaid
MS060048938OtherMEDICARE RAILROAD
MS060048938OtherMEDICARE RAILROAD
MS00118990Medicaid