Healthcare Provider Details

I. General information

NPI: 1528445632
Provider Name (Legal Business Name): EXECUTIVE HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 MASON ST
DEARBORN MI
48124-2841
US

IV. Provider business mailing address

1213 MASON ST
DEARBORN MI
48124-2841
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-2800
  • Fax: 313-278-0030
Mailing address:
  • Phone: 313-278-2800
  • Fax: 313-278-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MASSUD ALMASSUDI
Title or Position: PRESEDENT
Credential: MD
Phone: 313-278-2800