Provider Demographics
NPI:1427056068
Name:DEARBORN PEDIATRIC & ADOLESCENT MEDICAL CENTER, PC
Entity type:Organization
Organization Name:DEARBORN PEDIATRIC & ADOLESCENT MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOBNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELHASAN-FAKIH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-582-3700
Mailing Address - Street 1:6620 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4502
Mailing Address - Country:US
Mailing Address - Phone:313-582-3700
Mailing Address - Fax:313-582-3301
Practice Address - Street 1:6620 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4502
Practice Address - Country:US
Practice Address - Phone:313-582-3700
Practice Address - Fax:313-582-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064108261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4713462Medicaid
MI3479230Medicaid