Provider Demographics
NPI:1770769630
Name:FAIZ MANSOUR, M.D., P.C.
Entity type:Organization
Organization Name:FAIZ MANSOUR, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-334-3792
Mailing Address - Street 1:10 W SQUARE LAKE RD
Mailing Address - Street 2:202
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0465
Mailing Address - Country:US
Mailing Address - Phone:248-452-9500
Mailing Address - Fax:
Practice Address - Street 1:10 W SQUARE LAKE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0465
Practice Address - Country:US
Practice Address - Phone:248-452-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059179302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4255901Medicaid
G13783Medicare UPIN
MI4255901Medicaid