Basic Information
| Provider Information | |||||||||
| NPI: | 1578568036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL EMERGENCY CARE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 8888618740 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | EMERGENCY MEDICINE DEPARTMENT | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135938780 | ||||||||
| FaxNumber: | 8888618740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| 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 | 207RC0200X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208000000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700D410740 | 01 | BCBS | OTHER | 1578568036 | 05 | MI | MEDICAID | 010Q262940 | 01 | MI | BCBSMI | OTHER | 700E014610 | 01 | BCBS | OTHER | CC0535 | 01 | MI | RAILROAD MEDICARE | OTHER |