Provider Demographics
NPI:1871043000
Name:EAST DEARBORN MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:EAST DEARBORN MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-581-0200
Mailing Address - Street 1:14650 W WARREN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1799
Mailing Address - Country:US
Mailing Address - Phone:313-581-0200
Mailing Address - Fax:313-582-3300
Practice Address - Street 1:14650 W WARREN AVE
Practice Address - Street 2:STE 150
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1799
Practice Address - Country:US
Practice Address - Phone:313-581-0200
Practice Address - Fax:313-582-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069195261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care