Healthcare Provider Details

I. General information

NPI: 1609885151
Provider Name (Legal Business Name): NASSER ELSOURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST 11M
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4049 GLENCASTLE DR
TROY MI
48098-6342
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-3724
  • Fax:
Mailing address:
  • Phone: 313-737-9731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101268545
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301080157
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number35135469
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101268454
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301080157
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: