Provider Demographics
NPI:1881955953
Name:EXECUTIVE DIAGNOSTIC GROUP, PLLC
Entity type:Organization
Organization Name:EXECUTIVE DIAGNOSTIC GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:JORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-359-9361
Mailing Address - Street 1:1711 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2914
Mailing Address - Country:US
Mailing Address - Phone:313-359-9361
Mailing Address - Fax:313-436-1767
Practice Address - Street 1:1711 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2914
Practice Address - Country:US
Practice Address - Phone:313-359-9361
Practice Address - Fax:313-436-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038699261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty