=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417682766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHFIELD PREMIER PRIMARY CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2022
-----------------------------------------------------
Last Update Date | 07/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17070 W 12 MILE RD STE A
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-559-2280
-----------------------------------------------------
Fax | 248-559-3752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17070 W 12 MILE RD STE A
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-559-2280
-----------------------------------------------------
Fax | 248-559-3752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/PHYSICIAN
-----------------------------------------------------
Name | DR. RAFID MANSOUR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-559-2280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------