Provider Demographics
NPI:1821548181
Name:IMAD MANSOOR MD, PC
Entity type:Organization
Organization Name:IMAD MANSOOR MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-840-4312
Mailing Address - Street 1:42557 WOODWARD AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5206
Mailing Address - Country:US
Mailing Address - Phone:248-333-1170
Mailing Address - Fax:
Practice Address - Street 1:42557 WOODWARD AVE STE 110
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5206
Practice Address - Country:US
Practice Address - Phone:248-333-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty