Healthcare Provider Details

I. General information

NPI: 1386438380
Provider Name (Legal Business Name): ANTHONY SALEM
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 500
SOUTHFIELD MI
48075-6213
US

IV. Provider business mailing address

22250 PROVIDENCE DR STE 500
SOUTHFIELD MI
48075-6213
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3441
  • Fax: 248-849-4132
Mailing address:
  • Phone: 248-849-3441
  • Fax: 248-849-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351054273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: