Provider Demographics
NPI:1871777672
Name:MICHIGAN INTERNAL MEDICINE CENTER PC
Entity type:Organization
Organization Name:MICHIGAN INTERNAL MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NADAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-547-3914
Mailing Address - Street 1:928 BLOOMFIELD KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2015
Mailing Address - Country:US
Mailing Address - Phone:248-761-5185
Mailing Address - Fax:
Practice Address - Street 1:928 BLOOMFIELD KNOLL DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2015
Practice Address - Country:US
Practice Address - Phone:248-761-5185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075318207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104702923Medicaid
MI1106304251OtherBCBSM
MI1106304251OtherBCBSM
MI104702923Medicaid