Healthcare Provider Details

I. General information

NPI: 1992709331
Provider Name (Legal Business Name): PROFESSIONAL PLAZA CLINIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2395 W GRAND BLVD
DETROIT MI
48208-1210
US

IV. Provider business mailing address

2395 W GRAND BLVD
DETROIT MI
48208-1210
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-2442
  • Fax: 313-831-2444
Mailing address:
  • Phone: 313-831-2442
  • Fax: 313-831-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. ANDREA P MCBRIDE
Title or Position: CEO/PRESIDENT
Credential:
Phone: 313-218-2709