Provider Demographics
NPI:1053310128
Name:LAZ MEDICAL GROUP PC
Entity Type:Organization
Organization Name:LAZ MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAKARI
Authorized Official - Middle Name:
Authorized Official - Last Name:TATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-569-7550
Mailing Address - Street 1:PO BOX 250005
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-0005
Mailing Address - Country:US
Mailing Address - Phone:248-569-7550
Mailing Address - Fax:313-561-0277
Practice Address - Street 1:20755 GREENFIELD RD
Practice Address - Street 2:#1101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5403
Practice Address - Country:US
Practice Address - Phone:248-569-7550
Practice Address - Fax:313-561-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N83950Medicare ID - Type UnspecifiedGROUP MEDICARE