Provider Demographics
NPI:1396739769
Name:YACOUB, MICHAEL F (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:YACOUB
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 1:19251 MACK AVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2893
Mailing Address - Country:US
Mailing Address - Phone:313-343-7280
Mailing Address - Fax:313-343-7921
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-7280
Practice Address - Fax:313-343-7921
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4106213Medicaid
MI0Q262160OtherBLUE CROSS GROUP
4301067942OtherCONTROLLED SUBSTANCE
MI0Q262160OtherBLUE CROSS GROUP
MI4106213Medicaid