Basic Information
| Provider Information | |||||||||
| NPI: | 1083285597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANDMARK MEDICAL OF MICHIGAN PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7755 CENTER AVE STE 630 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926479152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6572372450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26677 W 12 MILE RD STE 166 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480341514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133062023 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2021 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DENNIS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF BH OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6574005180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.