Healthcare Provider Details

I. General information

NPI: 1154350890
Provider Name (Legal Business Name): CARDIOVASCULAR INSTITUTE OF MICHIGAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18303 E 10 MILE RD SUITE 100
ROSEVILLE MI
48066-4988
US

IV. Provider business mailing address

18303 E 10 MILE RD SUITE 100
ROSEVILLE MI
48066-4988
US

V. Phone/Fax

Practice location:
  • Phone: 586-776-8877
  • Fax: 586-776-3092
Mailing address:
  • Phone: 586-776-8877
  • Fax: 586-776-3092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMAD K AJJOUR
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 586-776-8877