Provider Demographics
NPI:1851581540
Name:BOU-ASSALY, WESSAM BOUTROS
Entity Type:Individual
Prefix:
First Name:WESSAM
Middle Name:BOUTROS
Last Name:BOU-ASSALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9155 MIRAGE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-9010
Mailing Address - Country:US
Mailing Address - Phone:317-828-0810
Mailing Address - Fax:
Practice Address - Street 1:2155 FULLER RD
Practice Address - Street 2:RADIOLOGY DEPARTMENT/ VA HEALTH CENTER
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-761-7959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-28
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010892432085N0700X, 2085R0202X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology