Healthcare Provider Details

I. General information

NPI: 1992565105
Provider Name (Legal Business Name): SOUTHFIELD REGENERATIVE MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17220 W 12 MILE RD STE 200
SOUTHFIELD MI
48076-2141
US

IV. Provider business mailing address

17220 W 12 MILE RD STE 205
SOUTHFIELD MI
48076-2114
US

V. Phone/Fax

Practice location:
  • Phone: 313-284-9433
  • Fax: 313-284-3180
Mailing address:
  • Phone: 313-284-9433
  • Fax: 313-284-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN HIJAZI
Title or Position: OWNER
Credential: DO
Phone: 313-284-9433