Healthcare Provider Details

I. General information

NPI: 1417403866
Provider Name (Legal Business Name): SOUTHEAST MICHIGAN ANESTHESIA GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 MICHIGAN AVE SUITE 100
DEARBORN MI
48126-3574
US

IV. Provider business mailing address

13530 MICHIGAN AVE SUITE 100
DEARBORN MI
48126-3574
US

V. Phone/Fax

Practice location:
  • Phone: 313-582-7777
  • Fax:
Mailing address:
  • Phone: 313-582-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: FATINA MASRI
Title or Position: AO
Credential:
Phone: 313-582-7777