=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972170652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASSEM SOUFAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2021
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 N HAGGERTY RD
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48187-3795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-446-9757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26901 BEAUMONT BLVD STE 3D
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301511386
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------