Healthcare Provider Details

I. General information

NPI: 1760700660
Provider Name (Legal Business Name): MICHIGAN SPECIALTY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 MICHIGAN AVE SUITE 120
DEARBORN MI
48126-3583
US

IV. Provider business mailing address

13530 MICHIGAN AVE STE 400
DEARBORN MI
48126-3575
US

V. Phone/Fax

Practice location:
  • Phone: 313-945-9188
  • Fax: 313-945-9184
Mailing address:
  • Phone: 313-945-9188
  • Fax: 313-945-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301052487
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number4301052487
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301052487
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number4301052487
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. FATINA MASRI
Title or Position: OWNER
Credential: M.D.
Phone: 313-945-9188