Provider Demographics
NPI:1396401543
Name:WAVE MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:WAVE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:NERGIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JASSIM
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:313-903-3338
Mailing Address - Street 1:21103 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2686
Mailing Address - Country:US
Mailing Address - Phone:313-903-3338
Mailing Address - Fax:
Practice Address - Street 1:17600 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3509
Practice Address - Country:US
Practice Address - Phone:313-903-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-11
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health