=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437969920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN VASCULAR SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5250 AUTO CLUB DR STE 300
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-724-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5250 AUTO CLUB DR STE 300
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-724-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KHALIL MASABNI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-957-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------