Provider Demographics
NPI:1386081529
Name:CANTON FAMILY MEDICINE AND MEDICAL SPA, PLLC
Entity type:Organization
Organization Name:CANTON FAMILY MEDICINE AND MEDICAL SPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANADOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-667-1648
Mailing Address - Street 1:5958 N CANTON CENTER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2765
Mailing Address - Country:US
Mailing Address - Phone:734-667-1648
Mailing Address - Fax:734-667-1649
Practice Address - Street 1:5958 N CANTON CENTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2765
Practice Address - Country:US
Practice Address - Phone:734-667-1648
Practice Address - Fax:734-667-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061850261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG51798Medicare UPIN