Healthcare Provider Details

I. General information

NPI: 1548825615
Provider Name (Legal Business Name): SAMANTHA FARIDA HANNOSH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2019
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax: 313-876-1305
Mailing address:
  • Phone: 800-999-5829
  • Fax: 248-641-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101025853
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: