Healthcare Provider Details

I. General information

NPI: 1245572460
Provider Name (Legal Business Name): MARK SHAMOUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HOSPITAL OF MI 3901 BEAUBIEN 2ND
DETROIT MI
48201
US

IV. Provider business mailing address

UNIVERSITY PEDIATRICIANS 4201 ST. ANTOINE UHC 5D # 226
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5515
  • Fax: 313-745-5237
Mailing address:
  • Phone: 313-966-5051
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301110072
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301110072
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: