Basic Information
| Provider Information | |||||||||
| NPI: | 1407392970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY MEDICAL CENTER OF MICHIGAN,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICAL CENTER OF MI-SOUTHGATE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8765 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPERANCE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481829583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348473802 | ||||||||
| FaxNumber: | 7348500520 | ||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346542169 | ||||||||
| FaxNumber: | 7346542535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2017 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LARKINS | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7348506914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | H19CS02960 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.