Basic Information
| Provider Information | |||||||||
| NPI: | 1548421167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOUREDDINE | ||||||||
| FirstName: | WASSIM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 3A | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 SPRING ARBOR RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492038602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172051000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301097637 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036120723 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD438106 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 4301097637 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 036120723 | 05 | IL | MEDICAID | 0222075 | 01 | IL | BLUE CROSS GROUP NUMBER | OTHER | 3631498336019001 | 01 | IL | CDPG HFS PAYEE ID | OTHER |