MEDICARE: ADVANCED CARDIOVASCULAR CLINIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0404X	Cardiac Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1912549056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED CARDIOVASCULAR CLINIC PC

Provider Business Mailing Address
First Line	:	6122 W PIERSON RD UNIT 1
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-3104
Country	:	US
Telephone Number	:	810-600-3399
Fax Number	:	810-600-3398

Provider Business Practice Location Address
First Line	:	6122 W PIERSON RD UNIT 1
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-3104
Country	:	US
Telephone Number	:	810-600-3399
Fax Number	:	810-600-3398

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	MOHAMMAD LUAY ALKOTOB
Credential	:	MD
Telephone Number	:	810-600-3399

Provider Enumeration Date	:	10/10/2019
Last Update Date	:	10/10/2019

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