Provider Demographics
NPI:1952715153
Name:EXECUTIVE PLAZA MEDICAL, P.C.
Entity type:Organization
Organization Name:EXECUTIVE PLAZA MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOSSAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOSSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-915-4632
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2793
Mailing Address - Country:US
Mailing Address - Phone:313-915-4632
Mailing Address - Fax:313-915-4634
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-915-4632
Practice Address - Fax:313-915-4634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006652208D00000X, 261QM1300X
MI4301405559261QM1300X
MI4301405324261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty