Provider Demographics
NPI:1982911830
Name:HERITAGE MEDICAL CLINIC PPLC
Entity Type:Organization
Organization Name:HERITAGE MEDICAL CLINIC PPLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALAYAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-483-9474
Mailing Address - Street 1:1159 E MICHIGAN AVE STE E
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5807
Mailing Address - Country:US
Mailing Address - Phone:734-483-9474
Mailing Address - Fax:734-483-9464
Practice Address - Street 1:1159 E MICHIGAN AVE STE E
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5807
Practice Address - Country:US
Practice Address - Phone:734-483-9474
Practice Address - Fax:734-483-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty