MEDICARE: MICHAEL BOUSAMRA II M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	01066681A	IN
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	35096	KY
3	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	4301503387	MI

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1669411781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL BOUSAMRA II M.D.

Provider Business Mailing Address
First Line	:	16001 W 9 MILE RD FL 3
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-4818
Country	:	US
Telephone Number	:	248-849-2600
Fax Number	:	248-849-2610

Provider Business Practice Location Address
First Line	:	19229 MACK AVE STE 23
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-2857
Country	:	US
Telephone Number	:	248-849-2600
Fax Number	:	248-849-2610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	12/11/2020

19229 MACK AVE STE 38
GROSSE POINTE WOODS, MI
48236-2857

Practice Phone: 313-647-3900
Practice Fax: