Provider Demographics
NPI:1861702433
Name:PRIME CARE MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:PRIME CARE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FOUAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAKHLALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-581-8080
Mailing Address - Street 1:13840 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1425
Mailing Address - Country:US
Mailing Address - Phone:313-581-8080
Mailing Address - Fax:313-581-8383
Practice Address - Street 1:13840 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1425
Practice Address - Country:US
Practice Address - Phone:313-581-8080
Practice Address - Fax:313-581-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4753252Medicaid