Healthcare Provider Details

I. General information

NPI: 1619266319
Provider Name (Legal Business Name): MUHANNAD ANTOUN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE AVENUE
WYANDOTTE MI
48192-9458
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number4301503853
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301503853
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number4301503853
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301503853
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2471C1106X
TaxonomyCardiac-Interventional Technology Radiologic Technologist
License Number4301503853
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: