Basic Information
| Provider Information | |||||||||
| NPI: | 1104406289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY DOC CLINIC AND URGENT CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 S STATE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481046188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343167880 | ||||||||
| FaxNumber: | 8888379061 | ||||||||
| Practice Location | |||||||||
| Address1: | 25350 W WARREN ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481272102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343167880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | NASRALLAH | ||||||||
| AuthorizedOfficialFirstName: | ALI | ||||||||
| AuthorizedOfficialMiddleName: | IBRAHIM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3139455450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 4301503083 | 05 | MI | MEDICAID |