Provider Demographics
NPI:1760700660
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:DR
Authorized Official - First Name:FATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-945-9188
Mailing Address - Street 1:13530 MICHIGAN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3575
Mailing Address - Country:US
Mailing Address - Phone:313-945-9188
Mailing Address - Fax:313-945-9184
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3583
Practice Address - Country:US
Practice Address - Phone:313-945-9188
Practice Address - Fax:313-945-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 207YS0012X, 207YX0905X, 291U00000X
MI4301052487207Y00000X, 207YX0007X, 208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H269700OtherBCBS GROUP
MI1760800660Medicaid
700H269700OtherBCN GROUP
MIDS8165OtherRAILROAD MEDICARE
MIMI2929Medicare PIN