Provider Demographics
NPI:1699852343
Name:MANSOUR MERCY MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:MANSOUR MERCY MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-443-5580
Mailing Address - Street 1:19011 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3984
Mailing Address - Country:US
Mailing Address - Phone:586-443-5580
Mailing Address - Fax:
Practice Address - Street 1:19011 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-3984
Practice Address - Country:US
Practice Address - Phone:586-443-5580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM078660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1105015892OtherBCBS
MI4717292Medicaid
MI4717292Medicaid
MII21667Medicare UPIN
MI0P13260Medicare ID - Type Unspecified