Provider Demographics
NPI:1699813006
Name:AMETHYST MEDICAL OFFICES PLC
Entity type:Organization
Organization Name:AMETHYST MEDICAL OFFICES PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSHUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-921-4327
Mailing Address - Street 1:8200 E JEFFERSON AVE
Mailing Address - Street 2:APT 709
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3974
Mailing Address - Country:US
Mailing Address - Phone:313-822-0308
Mailing Address - Fax:313-921-3628
Practice Address - Street 1:3741 MCDOUGALL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2345
Practice Address - Country:US
Practice Address - Phone:313-921-4327
Practice Address - Fax:313-921-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4241290Medicaid
MI1699869438OtherNPI
MIF04895Medicare UPIN
MI4241290Medicaid