Provider Demographics
NPI:1962045161
Name:MICHIGANS PREMIER FOOT AND ANKLE PLLC
Entity Type:Organization
Organization Name:MICHIGANS PREMIER FOOT AND ANKLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALAA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-808-9939
Mailing Address - Street 1:5861 DEEPWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-565-4948
Practice Address - Fax:313-565-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty