Provider Demographics
NPI:1578545638
Name:MOSSALLAM, SAMER (DO)
Entity Type:Individual
Prefix:MR
First Name:SAMER
Middle Name:
Last Name:MOSSALLAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3113
Mailing Address - Country:US
Mailing Address - Phone:734-457-9034
Mailing Address - Fax:734-457-9037
Practice Address - Street 1:1046 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3113
Practice Address - Country:US
Practice Address - Phone:734-457-9034
Practice Address - Fax:734-457-9037
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM012934207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1655800434OtherBLUE CARE NETWORK
MI1655800434OtherBLUE CROSS BLUE SHIELD
MIP00210239OtherRAILROAD MEDICARE
MI03570OtherPARAMOUNT
MI05500OtherHEALTHPLAN OF MICHIGAN
MI7112004OtherAETNA
MI0N91360Medicare ID - Type Unspecified
MIN9136003Medicare ID - Type Unspecified
MI7112004OtherAETNA