Provider Demographics
NPI:1912186214
Name:FAMILY MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:B
Authorized Official - Last Name:FAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-872-6000
Mailing Address - Street 1:10218 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3224
Mailing Address - Country:US
Mailing Address - Phone:313-872-6000
Mailing Address - Fax:
Practice Address - Street 1:10218 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3224
Practice Address - Country:US
Practice Address - Phone:313-872-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID