Healthcare Provider Details

I. General information

NPI: 1326335373
Provider Name (Legal Business Name): EBTISAM MOHAMED ALFAID M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

28364 DEPLANCHE LN
INKSTER MI
48141-2872
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1023
  • Fax: 313-916-5008
Mailing address:
  • Phone: 412-245-7389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301098106
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: