Provider Demographics
NPI:1053942060
Name:CANTON MEDICAL CLINIC
Entity type:Organization
Organization Name:CANTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LATIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-548-9602
Mailing Address - Street 1:37662 FORD RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1924
Mailing Address - Country:US
Mailing Address - Phone:734-238-3800
Mailing Address - Fax:734-238-3803
Practice Address - Street 1:37662 FORD RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1924
Practice Address - Country:US
Practice Address - Phone:734-238-3800
Practice Address - Fax:734-238-3803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235144759OtherNPI