=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265828115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHANNAD ABOUSALEH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2015
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 ELLIOTT DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-8632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-434-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 FORD PL
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-874-4806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 4301506278
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 35.136758
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------