Provider Demographics
NPI:1245929587
Name:BEYDOUN, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:BEYDOUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26516 LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3380
Mailing Address - Country:US
Mailing Address - Phone:313-580-1954
Mailing Address - Fax:
Practice Address - Street 1:4700 GREENFIELD RD STE 2E
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4124
Practice Address - Country:US
Practice Address - Phone:313-740-1111
Practice Address - Fax:313-672-6241
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704359368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner