Healthcare Provider Details

I. General information

NPI: 1083172878
Provider Name (Legal Business Name): JAAFER BEYDOUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 W 9 MILE RD STE 740
SOUTHFIELD MI
48075-4413
US

IV. Provider business mailing address

17515 W 9 MILE RD STE 740
SOUTHFIELD MI
48075-4413
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-2222
  • Fax: 248-262-3333
Mailing address:
  • Phone: 248-353-2222
  • Fax: 248-262-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704282698
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704282698
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: