Healthcare Provider Details

I. General information

NPI: 1699432286
Provider Name (Legal Business Name): ALLEN PRIMARY PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23801 W WARREN ST STE 102
DEARBORN HEIGHTS MI
48127-2277
US

IV. Provider business mailing address

1813 N ROSEVERE AVE
DEARBORN MI
48128-1242
US

V. Phone/Fax

Practice location:
  • Phone: 734-895-4530
  • Fax: 313-447-3234
Mailing address:
  • Phone: 734-895-4530
  • Fax: 313-447-3234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: ALEX BOUHACHEM
Title or Position: CEO
Credential: DPM
Phone: 734-895-4530