Provider Demographics
NPI:1134166895
Name:PORT HURON VASCULAR CLINIC PC
Entity type:Organization
Organization Name:PORT HURON VASCULAR CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SADIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-985-1300
Mailing Address - Street 1:2603 ELECTRIC AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6588
Mailing Address - Country:US
Mailing Address - Phone:810-985-1300
Mailing Address - Fax:810-985-1659
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6588
Practice Address - Country:US
Practice Address - Phone:810-985-1300
Practice Address - Fax:810-985-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G46016Medicare PIN