Basic Information
| Provider Information | |||||||||
| NPI: | 1326235698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL EMERGENCY CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 8888618740 | ||||||||
| Practice Location | |||||||||
| Address1: | 15855 19 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480383504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862632601 | ||||||||
| FaxNumber: | 8888618740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | BAUER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 7346320175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700E014610 | 01 | MI | BCBS | OTHER | 1326235698 | 05 | MI | MEDICAID | DB9172 | 01 | MI | RAILROAD MEDICARE | OTHER |