Provider Demographics
NPI:1962699843
Name:MADISON INTERNISTS P C
Entity type:Organization
Organization Name:MADISON INTERNISTS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAKEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-797-9063
Mailing Address - Street 1:3120 CARPENTER ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-9802
Mailing Address - Country:US
Mailing Address - Phone:313-891-5437
Mailing Address - Fax:313-891-0842
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3491
Practice Address - Country:US
Practice Address - Phone:248-542-2229
Practice Address - Fax:248-542-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078037261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4998578Medicaid
MI159966Medicare UPIN