Healthcare Provider Details

I. General information

NPI: 1205312428
Provider Name (Legal Business Name): MICHIGAN PRIMARY CARE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27250 CHERRY HILL RD
DEARBORN HEIGHTS MI
48127-3677
US

IV. Provider business mailing address

27250 CHERRY HILL RD
DEARBORN HEIGHTS MI
48127-3677
US

V. Phone/Fax

Practice location:
  • Phone: 313-406-2222
  • Fax: 313-908-2687
Mailing address:
  • Phone: 313-406-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301103085
License Number StateMI

VIII. Authorized Official

Name: DR. RODWAN FADLALLAH
Title or Position: PRESIDENT
Credential: MD
Phone: 313-406-2222