Provider Demographics
NPI:1780806810
Name:KINGSWOOD INTERNAL MEDICINE
Entity type:Organization
Organization Name:KINGSWOOD INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FAIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-334-3136
Mailing Address - Street 1:43097 WOODWARD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5041
Mailing Address - Country:US
Mailing Address - Phone:248-334-3136
Mailing Address - Fax:248-334-3871
Practice Address - Street 1:43097 WOODWARD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5041
Practice Address - Country:US
Practice Address - Phone:248-334-3136
Practice Address - Fax:248-334-3871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N18280Medicare ID - Type Unspecified