Provider Demographics
NPI:1871821389
Name:THWAINEY, BASSAM JABRAIL (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:JABRAIL
Last Name:THWAINEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BASSAM
Other - Middle Name:JABRAIL
Other - Last Name:ASSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15300 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2584
Mailing Address - Country:US
Mailing Address - Phone:248-968-2003
Mailing Address - Fax:248-968-2276
Practice Address - Street 1:15300 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237
Practice Address - Country:US
Practice Address - Phone:248-968-2276
Practice Address - Fax:248-968-2276
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine