Provider Demographics
NPI:1629715271
Name:MAROUN, WISSAM (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:MAROUN
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 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
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
Practice Address - Country:US
Practice Address - Phone:313-916-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2023-04-18
Deactivation Date:2023-03-20
Deactivation Code:
Reactivation Date:2023-04-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program