Provider Demographics
NPI:1619149010
Name:SUHA KASSAB DPM PC
Entity Type:Organization
Organization Name:SUHA KASSAB DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-333-4900
Mailing Address - Street 1:10 W SQUARE LAKE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0465
Mailing Address - Country:US
Mailing Address - Phone:248-333-4900
Mailing Address - Fax:248-333-4905
Practice Address - Street 1:10 W SQUARE LAKE RD
Practice Address - Street 2:STE300
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0465
Practice Address - Country:US
Practice Address - Phone:248-333-4900
Practice Address - Fax:248-333-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISK001415213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2592751Medicaid
MISK001415OtherBC LINCENSE
MI5825203Medicare PIN
MI2592751Medicaid
MIT34199Medicare UPIN