Provider Demographics
NPI:1902896608
Name:MANSOUR, ALAA G (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAA
Middle Name:G
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALAA
Other - Middle Name:G
Other - Last Name:MANSOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19011 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3984
Mailing Address - Country:US
Mailing Address - Phone:586-443-5580
Mailing Address - Fax:586-443-5590
Practice Address - Street 1:19011 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-3984
Practice Address - Country:US
Practice Address - Phone:586-443-5580
Practice Address - Fax:586-443-5580
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM078660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4717292Medicaid
MII21667OtherHAP
MI1105015892OtherBLUE CARE NETWORK
MIP00304762OtherRAILROAD MEDICARE
MI12852OtherCAPE HEALTH PLAN
MI16928OtherMCARE
MI139818OtherCARE CHOICES
MI029259OtherMIDWEST MEDICAID
MI149966OtherGREAT LAKES HEALTH PLAN
MII21667OtherHAP
MII21667Medicare UPIN