Provider Demographics
NPI:1386767473
Name:IMHOTEP MEDICAL SERVICES, INC.
Entity type:Organization
Organization Name:IMHOTEP MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-701-1187
Mailing Address - Street 1:5525 GREENWAY ST
Mailing Address - Street 2:SUITE B - 2
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2112
Mailing Address - Country:US
Mailing Address - Phone:313-701-1187
Mailing Address - Fax:313-931-9113
Practice Address - Street 1:5525 GREENWAY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2112
Practice Address - Country:US
Practice Address - Phone:313-935-0399
Practice Address - Fax:313-931-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM4301056553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4706980Medicaid
MI4706980Medicaid