=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699934158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINETREE MEDICAL CENTER, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 08/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4186 PONTIAC LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-935-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4186 PONTIAC LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-935-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SHAMIM A ISLAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-935-1931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------