Provider Demographics
NPI:1700267267
Name:MACOMB PRIMARY CARE, P.C.
Entity Type:Organization
Organization Name:MACOMB PRIMARY CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHADI
Authorized Official - Middle Name:H
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-323-0301
Mailing Address - Street 1:43393 SCHOENHERR ROAD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1959
Mailing Address - Country:US
Mailing Address - Phone:586-323-0301
Mailing Address - Fax:586-323-0341
Practice Address - Street 1:39915 GRAND RIVER AVENUE
Practice Address - Street 2:SUITE # 750
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2153
Practice Address - Country:US
Practice Address - Phone:248-476-7775
Practice Address - Fax:248-987-4972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
I35568Medicare UPIN