| Organization Name: | EXECUTIVE PLAZA MEDICAL, P.C. |
| NPI Number: | 1952715153 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | HOSSAM A HOSSEIN (MANAGER) |
| Mailing Address: | 17000 Executive Plaza Dr Suite 103 Dearborn |
| State: | MI US |
| Postal Code: | 481262793 |
| Phone Number: | 3139154632 |
| Fax Number: | 3139154634 |
| NPI Enumeration Date: | 06/16/2014 |
| NPI Last Update Date: | 01/13/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 5101006652 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |