MEDICARE: CAMBRIDGE INSTITUTE OF MINIMALLY INVASIVE THERAPIES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	4301098779	MI

General Provider Information

NPI Number	:	1376072488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMBRIDGE INSTITUTE OF MINIMALLY INVASIVE THERAPIES PLLC

Provider Business Mailing Address
First Line	:	25569 LOCH LOMOND DR
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-1031
Country	:	US
Telephone Number	:	313-779-8113
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 E 14 MILE RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-5905
Country	:	US
Telephone Number	:	586-244-9699
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MOHAMAD JABER
Credential	:	MD
Telephone Number	:	586-244-9699

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/12/2017

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