=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629003132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FATIMA HEALTH CARE,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 10/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4789 WESTLAND ST
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-582-0217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1135 FALCON ST
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48128-1341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-582-0217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | INSHAD H BEYDOUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-582-0217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 5601003140
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------