Provider Demographics
NPI:1740509116
Name:PHYSICIAN GROUP
Entity type:Organization
Organization Name:PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHFAQ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-444-4063
Mailing Address - Street 1:4870 W CLARK RD
Mailing Address - Street 2:STE 100 A
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1104
Mailing Address - Country:US
Mailing Address - Phone:734-444-4063
Mailing Address - Fax:
Practice Address - Street 1:4870 W CLARK RD
Practice Address - Street 2:STE 100A
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1104
Practice Address - Country:US
Practice Address - Phone:734-444-4063
Practice Address - Fax:734-418-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty