Provider Demographics
NPI:1457660789
Name:OLIVE TREE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:OLIVE TREE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JURATLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:313-451-8253
Mailing Address - Street 1:18181 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-5032
Mailing Address - Country:US
Mailing Address - Phone:313-451-8253
Mailing Address - Fax:313-451-8351
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-451-8253
Practice Address - Fax:313-451-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty