Provider Demographics
NPI:1992830863
Name:CANTON URGENT CARE PC
Entity Type:Organization
Organization Name:CANTON URGENT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BASSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTANTAWI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-844-2296
Mailing Address - Street 1:42464 CHERRY HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188
Mailing Address - Country:US
Mailing Address - Phone:734-844-2296
Mailing Address - Fax:734-844-3950
Practice Address - Street 1:42464 CHERRY HILL ROAD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188
Practice Address - Country:US
Practice Address - Phone:734-844-2296
Practice Address - Fax:734-844-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP25960Medicare ID - Type Unspecified