Provider Demographics
NPI:1578801080
Name:EASTBORN CLINIC PLLC
Entity Type:Organization
Organization Name:EASTBORN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUBALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:313-834-4444
Mailing Address - Street 1:7526 WYOMING ST
Mailing Address - Street 2:SUITE NUMBER 2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1690
Mailing Address - Country:US
Mailing Address - Phone:313-834-4444
Mailing Address - Fax:
Practice Address - Street 1:7526 WYOMING ST
Practice Address - Street 2:STE# 2
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1690
Practice Address - Country:US
Practice Address - Phone:313-834-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty