Healthcare Provider Details

I. General information

NPI: 1851581540
Provider Name (Legal Business Name): WESSAM BOUTROS BOU-ASSALY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2007
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 FULLER RD RADIOLOGY DEPARTMENT/ VA HEALTH CENTER
ANN ARBOR MI
48105
US

IV. Provider business mailing address

9155 MIRAGE LAKE DR
MILAN MI
48160-9010
US

V. Phone/Fax

Practice location:
  • Phone: 734-761-7959
  • Fax:
Mailing address:
  • Phone: 317-828-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM41968
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number4301089243
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301089243
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301089243
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: