Healthcare Provider Details

I. General information

NPI: 1295753101
Provider Name (Legal Business Name): AMGAD A. BISSADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36475 5 MILE RD MEDICAL STAFF OFFICE
LIVONIA MI
48154-1971
US

IV. Provider business mailing address

36475 5 MILE RD MEDICAL STAFF OFFICE
LIVONIA MI
48154-1971
US

V. Phone/Fax

Practice location:
  • Phone: 734-655-1420
  • Fax: 734-655-1445
Mailing address:
  • Phone: 734-655-1420
  • Fax: 734-655-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301005274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: