=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730693821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEGASUS DIAGNOSTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2017
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3686 BRANDI DR
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-312-3932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3686 BRANDI DR
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-312-3932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | TUFIQUL ISLAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-312-3932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------