1265591812 NPI number — FAMILY MEDICAL CENTER OF MICHIGAN,INC

Table of content: (NPI 1265591812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265591812 NPI number — FAMILY MEDICAL CENTER OF MICHIGAN,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CENTER OF MICHIGAN,INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTH MONROE COUNTY-CITIZENS' HEALTH COUNCIL, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265591812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8765 LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPERANCE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48182-9583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-847-3802
Provider Business Mailing Address Fax Number:
734-850-0520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8765 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPERANCE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48182-9583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-847-3802
Provider Business Practice Location Address Fax Number:
734-850-0520
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LARKINS
Authorized Official First Name:
ED
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
734-850-6914

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02214 . This is a "PARAMOUNT PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 18129 . This is a "BCBSM FACILITY CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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