Healthcare Provider Details

I. General information

NPI: 1720159304
Provider Name (Legal Business Name): LAKESIDE URGENT CARE, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44472 HAYES RD
CLINTON TOWNSHIP MI
48038-1090
US

IV. Provider business mailing address

44472 HAYES RD
CLINTON TOWNSHIP MI
48038-1090
US

V. Phone/Fax

Practice location:
  • Phone: 586-412-0890
  • Fax: 586-412-1065
Mailing address:
  • Phone: 586-412-0890
  • Fax: 586-412-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. FADI DEMASHKIEH
Title or Position: OWNER
Credential: MD
Phone: 586-412-0890