Provider Demographics
NPI:1023100500
Name:PATHOLOGY SPECIALISTS OF SOUTHEAST MICHIGAN PC
Entity type:Organization
Organization Name:PATHOLOGY SPECIALISTS OF SOUTHEAST MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-KHAFAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-343-3521
Mailing Address - Street 1:PO BOX 72572
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:800-288-8325
Practice Address - Fax:419-866-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI403788207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION94390Medicare PIN