Executive Diagnostic Group, PLLC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

License

4301038699 Issued in MI

Legal business name

EXECUTIVE DIAGNOSTIC GROUP, PLLC

Practice address

1711 Monroe St
Dearborn, MI 48124-2914

Phone

(313) 359-9361

Fax

(313) 436-1767

NPI assigned

Jun 5, 2012

Last updated

Sep 18, 2014By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Luis C Jorge, MD

Title

Owner

Phone

(313) 359-9361

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1338854400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1410998400000",
    "number": "1881955953",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1711 MONROE ST",
            "city": "DEARBORN",
            "state": "MI",
            "postal_code": "481242914",
            "telephone_number": "313-359-9361",
            "fax_number": "313-436-1767"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1711 MONROE ST",
            "city": "DEARBORN",
            "state": "MI",
            "postal_code": "481242914",
            "telephone_number": "313-359-9361",
            "fax_number": "313-436-1767"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXECUTIVE DIAGNOSTIC GROUP, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-05",
        "last_updated": "2014-09-18",
        "status": "A",
        "authorized_official_last_name": "JORGE",
        "authorized_official_first_name": "LUIS",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "313-359-9361",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "MI",
            "license": "4301038699",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Multi-Specialty Clinic/Center in Dearborn, MI
• Providers in Dearborn, MI by specialty
• Multi-Specialty Clinic/Center in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.