Healthcare Provider Details

I. General information

NPI: 1457660789
Provider Name (Legal Business Name): OLIVE TREE MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD SUITE 206
DEARBORN MI
48124-5032
US

IV. Provider business mailing address

18181 OAKWOOD BLVD SUITE 206
DEARBORN MI
48124-5032
US

V. Phone/Fax

Practice location:
  • Phone: 313-451-8253
  • Fax: 313-451-8351
Mailing address:
  • Phone: 313-451-8253
  • Fax: 313-451-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAM JURATLI
Title or Position: PRESIDENT
Credential: MD, MPH
Phone: 313-451-8253