Provider Demographics
NPI:1407178627
Name:JEFFERSON MEDICAL INDUSTRIAL CLINIC PC
Entity Type:Organization
Organization Name:JEFFERSON MEDICAL INDUSTRIAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARVIND
Authorized Official - Middle Name:S
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-259-9077
Mailing Address - Street 1:2141 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4128
Mailing Address - Country:US
Mailing Address - Phone:313-259-9077
Mailing Address - Fax:313-259-3722
Practice Address - Street 1:2141 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4128
Practice Address - Country:US
Practice Address - Phone:313-259-9077
Practice Address - Fax:313-259-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108297872OtherBCBS
MI1108297872OtherBCBS