=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528656667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTRACARE-DEARBORN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 01/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17000 EXECUTIVE PLAZA DR STE 103
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-2793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-880-3636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17000 EXECUTIVE PLAZA DR STE 103
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-2793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-880-3636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | YOUSEF ALMADRAHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-603-2544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------