MEDICARE: SAMIR DABBOUS, M.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician		MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RR PTAN C20625	OTHER	MI	MEDICARE RR

General Provider Information

NPI Number	:	1629004171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMIR DABBOUS, M.D., P.C.

Provider Business Mailing Address
First Line	:	22060 BEECH ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-2847
Country	:	US
Telephone Number	:	313-563-3640
Fax Number	:	313-563-0459

Provider Business Practice Location Address
First Line	:	22060 BEECH ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-2847
Country	:	US
Telephone Number	:	313-563-3640
Fax Number	:	313-563-0459

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. LEILA DABBOUS
Credential	:
Telephone Number	:	313-563-3640

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	10/15/2008

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