Provider Demographics
NPI:1912549056
Name:ADVANCED CARDIOVASCULAR CLINIC PC
Entity Type:Organization
Organization Name:ADVANCED CARDIOVASCULAR CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:LUAY
Authorized Official - Last Name:ALKOTOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-600-3399
Mailing Address - Street 1:6122 W PIERSON RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-3104
Mailing Address - Country:US
Mailing Address - Phone:810-600-3399
Mailing Address - Fax:810-600-3398
Practice Address - Street 1:6122 W PIERSON RD UNIT 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-3104
Practice Address - Country:US
Practice Address - Phone:810-600-3399
Practice Address - Fax:810-600-3398
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED CARDIOVASCULAR CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities