Provider Demographics
NPI:1508974999
Name:MANSOUR, FAIZ (MD)
Entity Type:Individual
Prefix:
First Name:FAIZ
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 1:10 W SQUARE LAKE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0467
Mailing Address - Country:US
Mailing Address - Phone:248-452-9500
Mailing Address - Fax:248-253-0443
Practice Address - Street 1:10 W SQUARE LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0467
Practice Address - Country:US
Practice Address - Phone:248-452-9500
Practice Address - Fax:248-253-0443
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0636377OtherBCBSM
MI383552831OtherCOMMERCIAL
MI4255901Medicaid
0P53500Medicare PIN
MI4255901Medicaid