Provider Demographics
NPI:1316917917
Name:GENNAOUI, ELIAS G (MD)
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:G
Last Name:GENNAOUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28011 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2952
Mailing Address - Country:US
Mailing Address - Phone:248-489-8177
Mailing Address - Fax:
Practice Address - Street 1:14825 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2642
Practice Address - Country:US
Practice Address - Phone:313-386-3930
Practice Address - Fax:313-386-0962
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037248207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3442150Medicaid
MIA74515Medicare UPIN
MI3442150Medicaid