1639689854 NPI number — MACOMB PRIMARY CARE, P.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639689854 NPI number — MACOMB PRIMARY CARE, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACOMB PRIMARY CARE, P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639689854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11051 HALL ROAD
Provider Second Line Business Mailing Address:
SUTIE 120
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-323-0301
Provider Business Mailing Address Fax Number:
286-323-0341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
851 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-354-0020
Provider Business Practice Location Address Fax Number:
586-323-0341
Provider Enumeration Date:
10/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MANSOUR
Authorized Official First Name:
CHADI
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
586-323-0301

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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