Healthcare Provider Details

I. General information

NPI: 1902896608
Provider Name (Legal Business Name): ALAA G MANSOUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALAA G MANSOUR M.D.

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/11/2025
Certification Date: 08/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 KELLY RD STE 100
EASTPOINTE MI
48021-3214
US

IV. Provider business mailing address

21321 KELLY RD STE 100
EASTPOINTE MI
48021-3214
US

V. Phone/Fax

Practice location:
  • Phone: 586-443-5580
  • Fax: 586-443-5590
Mailing address:
  • Phone: 586-443-5580
  • Fax: 586-443-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAM078660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: