Healthcare Provider Details

I. General information

NPI: 1629775580
Provider Name (Legal Business Name): EXECUTIVE MEDICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4260 MONROE ST
TOLEDO OH
43606-1944
US

IV. Provider business mailing address

17000 EXECUTIVE PLAZA DR STE 201
DEARBORN MI
48126-2793
US

V. Phone/Fax

Practice location:
  • Phone: 419-890-4666
  • Fax:
Mailing address:
  • Phone: 419-890-4666
  • Fax: 419-890-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: HASSAN ISMAIL
Title or Position: AO
Credential:
Phone: 419-890-4666