Provider Demographics
NPI:1336545417
Name:ELBAKOUSH, FAESAL
Entity Type:Individual
Prefix:
First Name:FAESAL
Middle Name:
Last Name:ELBAKOUSH
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 1:4201 ST. ANTOINE
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS UHC 5D MAILBOX# 226
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-966-8999
Practice Address - Fax:313-993-0390
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106817208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics