Provider Demographics
NPI:1457527582
Name:I&L MEDICAL GROUP & ASSOCIATES
Entity Type:Organization
Organization Name:I&L MEDICAL GROUP & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:AGBASSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-861-0073
Mailing Address - Street 1:21700 GREENFIELD RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2581
Mailing Address - Country:US
Mailing Address - Phone:248-967-8520
Mailing Address - Fax:
Practice Address - Street 1:14438 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3916
Practice Address - Country:US
Practice Address - Phone:313-861-0073
Practice Address - Fax:313-861-0027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I & L PROFESSIONAL MEDICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty