Provider Demographics
NPI:1518200211
Name:GIRGIS, MARIAN RAOUF
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:RAOUF
Last Name:GIRGIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:RAOUF AZIZ
Other - Last Name:WAHBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301103489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program