Provider Demographics
NPI:1194940627
Name:MICHIGAN FAMILY PHYSICIANS, PC
Entity type:Organization
Organization Name:MICHIGAN FAMILY PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PLESCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-522-7000
Mailing Address - Street 1:400 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3628
Mailing Address - Country:US
Mailing Address - Phone:734-522-7000
Mailing Address - Fax:734-522-7012
Practice Address - Street 1:400 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3628
Practice Address - Country:US
Practice Address - Phone:734-522-7000
Practice Address - Fax:734-522-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009187207Q00000X
MI5101014641207RC0000X
MI2085R0202X
MI4704136023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4331440Medicaid
MI11482711Medicaid
MI5633194OtherBCN PROVIDER ID
MI080H225910OtherBCBS PROVIDER ID
MI080H225910OtherBCN PROVIDER ID
MI114827202Medicaid
MI11482711Medicaid
MI114827202Medicaid
MIE34603Medicare UPIN
MI4331440Medicaid
MIE59902Medicare UPIN
MIOP23120002Medicare ID - Type UnspecifiedMEDICARE