Provider Demographics
NPI:1194742940
Name:IMID CONSULTANTS PC
Entity type:Organization
Organization Name:IMID CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR BILLER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-229-6255
Mailing Address - Street 1:PO BOX 33321
Mailing Address - Street 2:DRAWER 110
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-5321
Mailing Address - Country:US
Mailing Address - Phone:248-229-6255
Mailing Address - Fax:248-624-9825
Practice Address - Street 1:2300 HAGGERTY
Practice Address - Street 2:STE 1190
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-229-6255
Practice Address - Fax:248-624-9825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054621207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1106320881OtherBC
MI4474944Medicaid
1106320881OtherBC
E24566Medicare UPIN