Healthcare Provider Details

I. General information

NPI: 1053970624
Provider Name (Legal Business Name): JACKSON CARDIOLOGY CONSULTANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PAGE AVE
JACKSON MI
49201-2462
US

IV. Provider business mailing address

PO BOX 772603
DETROIT MI
48277-2603
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-3577
  • Fax: 517-787-4280
Mailing address:
  • Phone: 517-787-4414
  • Fax: 517-926-8926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAREQ BAGHAL
Title or Position: OWNER
Credential: MD
Phone: 517-787-3577