Provider Demographics
NPI:1053647131
Name:MOTOWN RESIDENTIAL PHYSICIAN PLLC
Entity Type:Organization
Organization Name:MOTOWN RESIDENTIAL PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-476-6385
Mailing Address - Street 1:852 CEDARGATE CT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2606
Mailing Address - Country:US
Mailing Address - Phone:248-659-7576
Mailing Address - Fax:
Practice Address - Street 1:852 CEDARGATE CT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2606
Practice Address - Country:US
Practice Address - Phone:248-659-7576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI023784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty