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General NPI Number Information
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NPI Number | 1740509116
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Entity Type | Organization
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Legal Business Name | PHYSICIAN GROUP
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Dates
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Enumeration Date | 05/25/2010
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Last Update Date | 10/11/2012
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Provider Practice Location Address
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Address Line | 4870 W CLARK RD STE 100A
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City | YPSILANTI
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State | MI
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Zip | 48197-1104
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Country | US
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Telephone | 734-444-4063
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Fax | 734-418-2774
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Provider Business Mailing Address
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Address Line | 4870 W CLARK RD STE 100 A
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City | YPSILANTI
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State | MI
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Zip | 48197-1104
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Country | US
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Telephone | 734-444-4063
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AISHA ASHFAQ
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Credential |
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Telephone | 734-444-4063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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