Provider Demographics
NPI:1790840379
Name:SCHAEFER MEDICAL CENTER DEARBORN PLC
Entity Type:Organization
Organization Name:SCHAEFER MEDICAL CENTER DEARBORN PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NESRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-624-0000
Mailing Address - Street 1:5245 SCHAEFER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3257
Mailing Address - Country:US
Mailing Address - Phone:313-624-0000
Mailing Address - Fax:313-624-0063
Practice Address - Street 1:5245 SCHAEFER RD
Practice Address - Street 2:SUITE A
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3257
Practice Address - Country:US
Practice Address - Phone:313-624-0000
Practice Address - Fax:313-624-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301055729OtherLICENSE
MI4301055729OtherLICENSE
MI=========OtherTAX IDENTIFICATION NUMBER
MIF67698Medicare UPIN