Provider Demographics
NPI:1205312428
Name:MICHIGAN PRIMARY CARE CENTER PC
Entity type:Organization
Organization Name:MICHIGAN PRIMARY CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FADLALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-406-2222
Mailing Address - Street 1:27250 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3677
Mailing Address - Country:US
Mailing Address - Phone:313-406-2222
Mailing Address - Fax:
Practice Address - Street 1:27250 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3677
Practice Address - Country:US
Practice Address - Phone:313-406-2222
Practice Address - Fax:313-908-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
MI4301103085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty