Provider Demographics
NPI:1114776119
Name:MUSSALLAM, BARAA GHASSAN (DO)
Entity type:Individual
Prefix:
First Name:BARAA
Middle Name:GHASSAN
Last Name:MUSSALLAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2920
Mailing Address - Country:US
Mailing Address - Phone:586-790-9003
Mailing Address - Fax:
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-790-9003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151016576207X00000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery