Provider Demographics
NPI:1073842241
Name:MACOMB PRIMARY CARE PC
Entity Type:Organization
Organization Name:MACOMB PRIMARY CARE PC
Other - Org Name:REVOLUTION WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHADI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-323-0301
Mailing Address - Street 1:PO BOX 3272
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48605-3272
Mailing Address - Country:US
Mailing Address - Phone:989-797-1400
Mailing Address - Fax:989-797-4077
Practice Address - Street 1:51850 DEQUINDRE RD STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-2806
Practice Address - Country:US
Practice Address - Phone:586-323-0301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty