Healthcare Provider Details

I. General information

NPI: 1023100500
Provider Name (Legal Business Name): PATHOLOGY SPECIALISTS OF SOUTHEAST MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

PO BOX 72572
CLEVELAND OH
44192-0002
US

V. Phone/Fax

Practice location:
  • Phone: 800-288-8325
  • Fax: 419-866-5453
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number403788
License Number StateMI

VIII. Authorized Official

Name: DR. BASIM AL-KHAFAJI
Title or Position: PRESIDENT
Credential: MD
Phone: 313-343-3521