Provider Demographics
NPI:1508107038
Name:PHOENIX MEDICAL SPA MDPC
Entity Type:Organization
Organization Name:PHOENIX MEDICAL SPA MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAGHIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-310-4300
Mailing Address - Street 1:6833 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1808
Mailing Address - Country:US
Mailing Address - Phone:313-584-2260
Mailing Address - Fax:
Practice Address - Street 1:7105 ALLEN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2009
Practice Address - Country:US
Practice Address - Phone:313-381-7130
Practice Address - Fax:313-381-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0951827OtherBLUE CROSS BLUE SHIELD