Healthcare Provider Details

I. General information

NPI: 1134166895
Provider Name (Legal Business Name): PORT HURON VASCULAR CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 ELECTRIC AVE SUITE C
PORT HURON MI
48060-6588
US

IV. Provider business mailing address

2603 ELECTRIC AVE SUITE C
PORT HURON MI
48060-6588
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-1300
  • Fax: 810-985-1659
Mailing address:
  • Phone: 810-985-1300
  • Fax: 810-985-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SADIQ HUSSAIN
Title or Position: PRESIDENT
Credential: MD
Phone: 810-985-1300