Basic Information
| Provider Information | |||||||||
| NPI: | 1780696328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN MEDICAL ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 851 S MAIN ST STE B | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344535100 | ||||||||
| FaxNumber: | 7344533538 | ||||||||
| Practice Location | |||||||||
| Address1: | 851 S MAIN ST STE B | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344535100 | ||||||||
| FaxNumber: | 7344533538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | ATWOOD | ||||||||
| AuthorizedOfficialFirstName: | YOLA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7344535100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1649242280 | 01 | 1649242280 | OTHER | 15786063 | 01 | MI | 1578608063 | OTHER |