MEDICARE: CATHEDRAL COMMUNITY MEDICAL CLINIC PC

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	207R00000X	Internal Medicine Physician	4301064977	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649289844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHEDRAL COMMUNITY MEDICAL CLINIC PC

Provider Business Mailing Address
First Line	:	26515 BALDWIN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1908
Country	:	US
Telephone Number	:	313-205-0909
Fax Number	:	313-562-0751

Provider Business Practice Location Address
First Line	:	26515 BALDWIN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1908
Country	:	US
Telephone Number	:	313-205-0909
Fax Number	:	313-562-0751

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FADY FAYAD
Credential	:	M.D.
Telephone Number	:	313-205-0909

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	12/09/2010

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