Provider Demographics
NPI:1730121443
Name:ABDO, BASIL OMAR (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:OMAR
Last Name:ABDO
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 1:24224 JOY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1215
Mailing Address - Country:US
Mailing Address - Phone:313-561-9090
Mailing Address - Fax:313-561-3646
Practice Address - Street 1:24224 JOY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1215
Practice Address - Country:US
Practice Address - Phone:313-561-9090
Practice Address - Fax:313-561-3646
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301081899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E012740OtherBCBS GROUP NUMBER
080F334280OtherBCBSM
MI4896139/10Medicaid
MI08-0950225-2OtherBCBS INDIVIDUAL PIN #
MI08-0950225-2OtherBCBS INDIVIDUAL PIN #
080F334280OtherBCBSM
MI700E012740OtherBCBS GROUP NUMBER
I55785Medicare UPIN