Healthcare Provider Details

I. General information

NPI: 1194309815
Provider Name (Legal Business Name): MD 1ST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 05/09/2021
Certification Date: 05/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26346 GIBRALTAR RD
FLAT ROCK MI
48134-1522
US

IV. Provider business mailing address

26346 GIBRALTAR RD
FLAT ROCK MI
48134-1522
US

V. Phone/Fax

Practice location:
  • Phone: 313-970-0090
  • Fax:
Mailing address:
  • Phone: 313-970-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANA EL MASRI
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 248-215-0048