Healthcare Provider Details

I. General information

NPI: 1700337227
Provider Name (Legal Business Name): PRIME VASCULAR CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G-5103 MILLER RD
FLINT MI
48507-1043
US

IV. Provider business mailing address

G-5103 MILLER RD
FLINT MI
48507-1043
US

V. Phone/Fax

Practice location:
  • Phone: 810-600-2269
  • Fax: 810-720-3367
Mailing address:
  • Phone: 810-600-2269
  • Fax: 810-720-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301075121
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number4301075121
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberAA062994
License Number StateMI

VIII. Authorized Official

Name: MR. SAMIR A ELIAN
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 810-600-2269