Provider Demographics
NPI:1386031581
Name:IAMERICA MEDICAL
Entity Type:Organization
Organization Name:IAMERICA MEDICAL
Other - Org Name:IAMERICA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RABIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LATIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-307-0088
Mailing Address - Street 1:19445 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3361
Mailing Address - Country:US
Mailing Address - Phone:313-558-9397
Mailing Address - Fax:734-661-4501
Practice Address - Street 1:19451 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3361
Practice Address - Country:US
Practice Address - Phone:313-307-0088
Practice Address - Fax:734-661-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-25
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 333600000X
MI510100975208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386031581Medicaid