Provider First Line Business Practice Location Address:
1560 E MAPLE RD
Provider Second Line Business Practice Location Address:
SUITE 400-CREDENTIALING DEPARTMENT
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-7999
Provider Business Practice Location Address Fax Number:
313-745-4707
Provider Enumeration Date:
08/23/2006