Healthcare Provider Details

I. General information

NPI: 1962092213
Provider Name (Legal Business Name): ENDOVASCULAR CENTER OF AMERICA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PAGE AVE STE A
JACKSON MI
49201-2462
US

IV. Provider business mailing address

205 PAGE AVE STE A
JACKSON MI
49201-2462
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-3577
  • Fax:
Mailing address:
  • Phone: 517-787-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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