Healthcare Provider Details

I. General information

NPI: 1205834470
Provider Name (Legal Business Name): MANAF MADOUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

IV. Provider business mailing address

28925 HARPER AVE
SAINT CLAIR SHORES MI
48081-1272
US

V. Phone/Fax

Practice location:
  • Phone: 586-552-0269
  • Fax: 586-279-0833
Mailing address:
  • Phone: 586-552-0269
  • Fax: 586-279-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301073570
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: