Provider Demographics
NPI:1689216699
Name:MY CLINIC PLLC
Entity Type:Organization
Organization Name:MY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:EL MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-215-0048
Mailing Address - Street 1:4025 MAPLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3532
Mailing Address - Country:US
Mailing Address - Phone:313-269-4184
Mailing Address - Fax:
Practice Address - Street 1:4025 MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3532
Practice Address - Country:US
Practice Address - Phone:313-269-4184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty