Provider Demographics
NPI:1548421167
Name:NOUREDDINE, WASSIM (MD)
Entity Type:Individual
Prefix:DR
First Name:WASSIM
Middle Name:
Last Name:NOUREDDINE
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 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:3333 SPRING ARBOR RD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-8602
Practice Address - Country:US
Practice Address - Phone:517-205-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097637207R00000X, 207RE0101X
IL036120723207R00000X
PAMD438106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120723Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
IL3631498336019001OtherCDPG HFS PAYEE ID
IL3631498336019001OtherCDPG HFS PAYEE ID
ILR03022Medicare PIN
ILP00656803Medicare PIN
IL206147Medicare PIN