Provider Demographics
NPI:1417677030
Name:MICHIGAN INNOVATIVE DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:MICHIGAN INNOVATIVE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:GABALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-717-2895
Mailing Address - Street 1:50505 SCHOENHERR RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3141
Mailing Address - Country:US
Mailing Address - Phone:734-717-2895
Mailing Address - Fax:248-927-5004
Practice Address - Street 1:50505 SCHOENHERR RD STE 150
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3141
Practice Address - Country:US
Practice Address - Phone:586-991-6985
Practice Address - Fax:248-927-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory