Healthcare Provider Details

I. General information

NPI: 1528028651
Provider Name (Legal Business Name): SOUHEIL GEBARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE. 707
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

3601 W 13 MILE RD 400-FSC/PCS
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-0487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number4301406737
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: