Basic Information
| Provider Information | |||||||||
| NPI: | 1730121054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAKER MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3951 BOULDER DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489693220 | ||||||||
| FaxNumber: | 2482745059 | ||||||||
| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
| Address2: | SUITE 805 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | SAKER | ||||||||
| AuthorizedOfficialFirstName: | SAFWAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2489693220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301063663 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1108269021 | 01 | MI | BCBSM | OTHER | 4963367 | 05 | MI | MEDICAID |