Provider Demographics
NPI:1700407954
Name:MINI INVASIVE PODIATRY PLC
Entity Type:Organization
Organization Name:MINI INVASIVE PODIATRY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYER
Authorized Official - Prefix:
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ATEYAH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-303-6195
Mailing Address - Street 1:3058 METROPOLITAN PKWY STE 206
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3680
Mailing Address - Country:US
Mailing Address - Phone:586-434-3444
Mailing Address - Fax:586-434-3445
Practice Address - Street 1:3058 METROPOLITAN PKWY STE 206
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3680
Practice Address - Country:US
Practice Address - Phone:586-434-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962968719Medicaid