Healthcare Provider Details

I. General information

NPI: 1700519469
Provider Name (Legal Business Name): ANAS IDRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BOULEVARD
DETROIT MI
48202
US

IV. Provider business mailing address

2799 W GRAND BOULEVARD
DETROIT MI
48202-2689
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1601
  • Fax:
Mailing address:
  • Phone: 313-916-1601
  • Fax: 313-916-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: