Basic Information
| Provider Information | |||||||||
| NPI: | 1356876106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACOMB MEDICAL AND WELLNESS CENTER PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MACOMB MEDICAL AND WELLNESS C | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27170 DEQUINDRE RD STE B | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480923537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483522000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27170 DEQUINDRE RD STE B | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480923537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483522000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MICHEL | ||||||||
| AuthorizedOfficialFirstName: | JEAN-LUC | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5863935439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | MI | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.