Provider Demographics
NPI:1720008626
Name:AFANEH, BASSAM AHMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:AHMAD
Last Name:AFANEH
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 1:3925 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2287
Mailing Address - Country:US
Mailing Address - Phone:989-459-2300
Mailing Address - Fax:
Practice Address - Street 1:3925 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2287
Practice Address - Country:US
Practice Address - Phone:989-341-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058398208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4499667Medicaid
OM32640011Medicare ID - Type Unspecified
MI4499667Medicaid