Provider Demographics
NPI:1104860212
Name:UNIVERSAL CLINIC P.C.
Entity Type:Organization
Organization Name:UNIVERSAL CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-569-5100
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037
Mailing Address - Country:US
Mailing Address - Phone:248-569-5100
Mailing Address - Fax:248-569-4774
Practice Address - Street 1:18597 W 10 MILE RD
Practice Address - Street 2:STE #1
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2663
Practice Address - Country:US
Practice Address - Phone:248-569-5100
Practice Address - Fax:248-569-4774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N63000Medicare ID - Type Unspecified