=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497202253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNAPOLIS MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2016
-----------------------------------------------------
Last Update Date | 09/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4811 VENOY RD STE B
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48184-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-415-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 CHERRY LN
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AHMAD YOUSSEF
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 313-415-5254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 5101021767
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------