Provider Demographics
NPI:1487052619
Name:PROVIDENCE PARK INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:PROVIDENCE PARK INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:QASIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-891-4074
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 450
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-891-4074
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 450
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-891-4074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089716207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty