Healthcare Provider Details

I. General information

NPI: 1770419806
Provider Name (Legal Business Name): ANSAM AL-DALAL'A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN CHILDREN'S HOSPITAL OF MICHIGAN
DETROIT MI
48201
US

IV. Provider business mailing address

3901 BEAUBIEN CHILDREN'S HOSPITAL OF MICHIGAN
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-0225
  • Fax: 313-993-7118
Mailing address:
  • Phone: 313-966-0225
  • Fax: 313-993-7118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351057032
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: