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General NPI Number Information
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NPI Number | 1205000205
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Entity Type | Organization
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Legal Business Name | ELIAS G GENNAOUI M.D. PC
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 14825 SOUTHFIELD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-2642
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Country | US
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Telephone | 313-386-3930
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Fax | 313-386-0962
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Provider Business Mailing Address
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Address Line | 14825 SOUTHFIELD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-2642
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Country | US
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Telephone | 313-386-3930
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Fax | 313-386-0962
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Authorized Official
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Title or Position | OWNER
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Name | ELIAS G GENNAOUI
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Credential | M.D.
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Telephone | 313-386-3930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | EG037248
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License Number State | MI
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