Basic Information
| Provider Information | |||||||||
| NPI: | 1104868371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 67000 | ||||||||
| Address2: | DEPARTMENT 272801 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HINCKLEY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492036125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177840588 | ||||||||
| FaxNumber: | 5177843866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301045040 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00402205 | 01 | MI | RR MEDICARE | OTHER | 080083111 | 01 | MI | RAILROAD MEDICARE | OTHER | 105190507 | 05 | MI | MEDICAID | 5340399 | 01 | CIGNA | OTHER | 5464083 | 01 | AETNA USHEALTHCARE | OTHER |