NPIMap

Organization Active NPI

Eastlake Cardiovascular PC

  • Cardiovascular Disease Physician
  • St Clair Shores, MI
National Provider Identifier
1982657474
Registry record updated Dec 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Cardiovascular Disease PhysicianTaxonomy code 207RC0000X
Legal business name
EASTLAKE CARDIOVASCULAR PC
Practice address
24211 Little Mack Ave
St Clair Shores, MI 48080-1190
Phone
(586) 498-0440
Fax
(586) 498-0401
NPI assigned
May 18, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 1, 2020

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

Authorized official

Name
Dr. George B Ghanem, MDNPI 1104899269
Title
President
Phone
(586) 498-0440

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RC0000X MI Primary

Addresses

Primary practice location

24211 Little Mack Ave
St Clair Shores, MI 48080-1190

Mailing address

24211 Little Mack Ave
St Clair Shores, MI 48080-1190
Phone (586) 498-0440

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address gghafari24909@direct.beaumont.edu

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040308000049 MI Part B Supplier - Clinic/Group Practice 4688562176 Receives reassigned benefits from 29 practitioners
Practice locations: Clinton Township, MI; Troy, MI; Saint Clair Shores, MI; Roseville, MI; Rochester Hills, MI; Macomb, MI; Grosse Pointe, MI

National Provider Directory

National Provider Directory

Locations

16815 E Jefferson Ave
Ste 110
Grosse Pointe, MI 48230
Phone (313) 509-2212

16700 21 Mile Rd
Ste 106
Macomb, MI 48044
Phone (586) 566-5949

2061 W Auburn Rd
Rochester Hills, MI 48309
Phone (248) 923-2002

25990 Kelly Rd
Ste 2
Roseville, MI 48066
Phone (586) 498-0440

24211 Little Mack Ave
Ste A
Saint Clair Shores, MI 48080
Phone (586) 498-0440

44199 Dequindre Rd
Ste 504
Troy, MI 48085

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 31

NPI Registry JSON

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

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1606780800000",
    "number": "1982657474",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24211 LITTLE MACK AVE",
            "city": "ST CLAIR SHORES",
            "state": "MI",
            "postal_code": "480801190",
            "telephone_number": "586-498-0440",
            "fax_number": "586-498-0401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24211 LITTLE MACK AVE",
            "city": "ST CLAIR SHORES",
            "state": "MI",
            "postal_code": "480801190",
            "telephone_number": "586-498-0440",
            "fax_number": "586-498-0401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTLAKE CARDIOVASCULAR PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-18",
        "last_updated": "2020-12-01",
        "certification_date": "2020-12-01",
        "status": "A",
        "authorized_official_last_name": "GHANEM",
        "authorized_official_first_name": "GEORGE",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "586-498-0440",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "MI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "gghafari24909@direct.beaumont.edu",
            "affiliation": "N",
            "address_1": "24211 Little Mack Ave",
            "city": "St Clair Shores",
            "state": "MI",
            "country_code": "US",
            "postal_code": "480801190",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in St Clair Shores, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.