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General NPI Number Information
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NPI Number | 1952715153
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Entity Type | Organization
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Legal Business Name | EXECUTIVE PLAZA MEDICAL, P.C.
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Dates
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Enumeration Date | 06/16/2014
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Last Update Date | 01/13/2015
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Provider Practice Location Address
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Address Line | 17000 EXECUTIVE PLAZA DR SUITE 103
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City | DEARBORN
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State | MI
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Zip | 48126-2793
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Country | US
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Telephone | 313-915-4632
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Fax | 313-915-4634
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Provider Business Mailing Address
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Address Line | 17000 EXECUTIVE PLAZA DR SUITE 103
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City | DEARBORN
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State | MI
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Zip | 48126-2793
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Country | US
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Telephone | 313-915-4632
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Fax | 313-915-4634
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Authorized Official
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Title or Position | MANAGER
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Name | HOSSAM A HOSSEIN
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Credential |
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Telephone | 313-915-4632
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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 | 5101006652
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 4301405559
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 4301405324
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 5101006652
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License Number State | MI
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