=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538585260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH LAKE URGENT CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2014
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2446 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-561-1291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70747
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-0015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | FADI DEMASHKIEH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-561-1291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------