Provider Demographics
NPI:1457882888
Name:MICHIGAN SPECIALTY CLINIC PLLC
Entity Type:Organization
Organization Name:MICHIGAN SPECIALTY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-945-9188
Mailing Address - Street 1:13530 MICHIGAN AVE
Mailing Address - Street 2:SUITE L2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3574
Mailing Address - Country:US
Mailing Address - Phone:313-945-9188
Mailing Address - Fax:313-582-2545
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:SUITE L2
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:313-945-9188
Practice Address - Fax:313-582-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D21505179OtherCLIA OF REGISTRATION