Provider Demographics
NPI:1003434754
Name:PROSPERITY HEALTH PC
Entity Type:Organization
Organization Name:PROSPERITY HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NISHATH
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-997-4242
Mailing Address - Street 1:41000 WOODWARD AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5092
Mailing Address - Country:US
Mailing Address - Phone:248-997-4242
Mailing Address - Fax:
Practice Address - Street 1:41000 WOODWARD AVE STE 350
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5092
Practice Address - Country:US
Practice Address - Phone:248-997-4242
Practice Address - Fax:248-997-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083694830OtherINDIVIDUAL NPI
MI4301063552OtherSTATE LICENSE