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General NPI Number Information
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NPI Number | 1881955953
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Entity Type | Organization
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Legal Business Name | EXECUTIVE DIAGNOSTIC GROUP, PLLC
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Dates
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Enumeration Date | 06/05/2012
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Last Update Date | 09/18/2014
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Provider Practice Location Address
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Address Line | 1711 MONROE ST
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City | DEARBORN
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State | MI
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Zip | 48124-2914
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Country | US
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Telephone | 313-359-9361
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Fax | 313-436-1767
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Provider Business Mailing Address
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Address Line | 1711 MONROE ST
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City | DEARBORN
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State | MI
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Zip | 48124-2914
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Country | US
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Telephone | 313-359-9361
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Fax | 313-436-1767
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Authorized Official
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Title or Position | OWNER
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Name | DR. LUIS C JORGE
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Credential | MD
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Telephone | 313-359-9361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 4301038699
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License Number State | MI
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