Healthcare Provider Details

I. General information

NPI: 1053942060
Provider Name (Legal Business Name): CANTON MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37662 FORD RD
WESTLAND MI
48185-1924
US

IV. Provider business mailing address

37662 FORD RD
WESTLAND MI
48185-1924
US

V. Phone/Fax

Practice location:
  • Phone: 734-238-3800
  • Fax: 734-238-3803
Mailing address:
  • Phone: 734-238-3800
  • Fax: 734-238-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIDA LATIF
Title or Position: OWNER
Credential: MD
Phone: 269-548-9602