Provider Demographics
NPI:1194309815
Name:MD 1ST PLLC
Entity type:Organization
Organization Name:MD 1ST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:EL MASRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-215-0048
Mailing Address - Street 1:26346 GIBRALTAR RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-1522
Mailing Address - Country:US
Mailing Address - Phone:313-970-0090
Mailing Address - Fax:
Practice Address - Street 1:26346 GIBRALTAR RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-1522
Practice Address - Country:US
Practice Address - Phone:313-970-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-09
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care