Basic Information
| Provider Information | |||||||||
| NPI: | 1881752301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLESSINGS MEDICAL CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4828 W WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482101470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135065706 | ||||||||
| FaxNumber: | 2482745059 | ||||||||
| Practice Location | |||||||||
| Address1: | 4828 W WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482101470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135065706 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAKKAK | ||||||||
| AuthorizedOfficialFirstName: | WAAD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3135065706 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301407507 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10 4966995 | 05 | MI | MEDICAID | 110H203000 | 01 | MI | BCBSM | OTHER |