Basic Information
Provider Information | |||||||||
NPI: | 1841299435 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOODLAND URGENT CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 32588 | ||||||||
Address2: | 02 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482320588 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133878700 | ||||||||
FaxNumber: | 3133877665 | ||||||||
Practice Location | |||||||||
Address1: | 22341 W 8 MILE RD | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482191217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133878700 | ||||||||
FaxNumber: | 3133877665 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 12/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IFTIKHAR | ||||||||
AuthorizedOfficialFirstName: | FARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 3133878700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301065784 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 261QU0200X | 4301075100 | MI | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | 4301065784 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4603200 | 05 | MI |   | MEDICAID | 700H221550 | 01 | MI | BCBS | OTHER | 4603184 | 05 | MI |   | MEDICAID | 700H222890 | 01 | MI | BCN | OTHER |