Healthcare Provider Details

I. General information

NPI: 1811633241
Provider Name (Legal Business Name): REQUIEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 N MAIN ST STE 211
ROCHESTER MI
48307-1485
US

IV. Provider business mailing address

145 S LIVERNOIS RD # 336
ROCHESTER HILLS MI
48307-1837
US

V. Phone/Fax

Practice location:
  • Phone: 248-495-2438
  • Fax:
Mailing address:
  • Phone: 248-495-2438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: PIERRE CHARBEL ATALLAH
Title or Position: MANAGING MEMBER
Credential: MD, MS, MBA
Phone: 248-495-2438