Provider Demographics
NPI:1629601745
Name:ADVANCED FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:ADVANCED FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HAISSAM
Authorized Official - Middle Name:GHALEB
Authorized Official - Last Name:EL-TAKECH
Authorized Official - Suffix:
Authorized Official - Credentials:SAMIRA DGHAILY
Authorized Official - Phone:313-632-1351
Mailing Address - Street 1:6636 N TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2200
Mailing Address - Country:US
Mailing Address - Phone:313-632-1349
Mailing Address - Fax:313-274-3343
Practice Address - Street 1:6636 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2200
Practice Address - Country:US
Practice Address - Phone:313-274-3123
Practice Address - Fax:313-274-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty