Provider Demographics
NPI:1982657474
Name:EASTLAKE CARDIOVASCULAR PC
Entity Type:Organization
Organization Name:EASTLAKE CARDIOVASCULAR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GHANEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-498-0440
Mailing Address - Street 1:24211 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1190
Mailing Address - Country:US
Mailing Address - Phone:586-498-0440
Mailing Address - Fax:586-498-0401
Practice Address - Street 1:24211 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1190
Practice Address - Country:US
Practice Address - Phone:586-498-0440
Practice Address - Fax:586-498-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty