Provider Demographics
NPI:1730646977
Name:MICHIGAN SPECIALTY CLINIC PLLC
Entity Type:Organization
Organization Name:MICHIGAN SPECIALTY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-945-9800
Mailing Address - Street 1:13510 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3511
Mailing Address - Country:US
Mailing Address - Phone:313-582-0100
Mailing Address - Fax:
Practice Address - Street 1:13510 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3511
Practice Address - Country:US
Practice Address - Phone:313-582-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1760700660Medicaid