Basic Information
Provider Information | |||||||||
NPI: | 1265591812 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY MEDICAL CENTER OF MICHIGAN,INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH MONROE COUNTY-CITIZENS' HEALTH COUNCIL, INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8765 LEWIS AVE | ||||||||
Address2: |   | ||||||||
City: | TEMPERANCE | ||||||||
State: | MI | ||||||||
PostalCode: | 481829583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348473802 | ||||||||
FaxNumber: | 7348500520 | ||||||||
Practice Location | |||||||||
Address1: | 8765 LEWIS AVE | ||||||||
Address2: |   | ||||||||
City: | TEMPERANCE | ||||||||
State: | MI | ||||||||
PostalCode: | 481829583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348473802 | ||||||||
FaxNumber: | 7348500520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2006 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LARKINS | ||||||||
AuthorizedOfficialFirstName: | ED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7348506914 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BA, MBA, MHA | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 02214 | 01 | MI | PARAMOUNT PROVIDER NUMBER | OTHER | 18129 | 01 | MI | BCBSM FACILITY CODE | OTHER |