Provider Demographics
NPI:1992565105
Name:SOUTHFIELD REGENERATIVE MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:SOUTHFIELD REGENERATIVE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIJAZI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-284-9433
Mailing Address - Street 1:17220 W 12 MILE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2114
Mailing Address - Country:US
Mailing Address - Phone:313-284-9433
Mailing Address - Fax:313-284-3180
Practice Address - Street 1:17220 W 12 MILE RD STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2141
Practice Address - Country:US
Practice Address - Phone:313-284-9433
Practice Address - Fax:313-284-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-22
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty