Provider Demographics
NPI:1932195203
Name:ABOU-SAMRA, ABDUL-BADI (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ABDUL-BADI
Middle Name:
Last Name:ABOU-SAMRA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:ABDUL
Other - Middle Name:B
Other - Last Name:SAMRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:3800 WOODWARD AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 917
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089157207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA724182OtherTUFTS
MA8327117-001OtherCIGNA PAL #'S
MA3071405Medicaid
MA58956OtherLICENSE NUMBER
MA5904607OtherAETNA:
MAE80629042MGHOtherHPHC- PBO
MAUNITED-PBOOther3304179
MAE80629MGHOtherHPHC-ACD
MAE80629MGHOtherHPHC-ACD
MAJ10690Medicare ID - Type Unspecified
MA3071405Medicaid