Provider Demographics
NPI:1780850560
Name:SARMAD AL-MANSOUR, MD, PC
Entity type:Organization
Organization Name:SARMAD AL-MANSOUR, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARMAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:AL-MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-4777
Mailing Address - Street 1:8889 LAMONT
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150
Mailing Address - Country:US
Mailing Address - Phone:248-353-4777
Mailing Address - Fax:248-353-4235
Practice Address - Street 1:22972 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033
Practice Address - Country:US
Practice Address - Phone:248-353-4777
Practice Address - Fax:248-353-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA053934207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4926846Medicaid
MI1106356921OtherMICHIGAN BCBS
MI4931882Medicaid
MI4931882Medicaid
0N93310Medicare PIN