Provider Demographics
NPI:1083019848
Name:ADVANCED PHYSICIAN GROUP PLLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICIAN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-673-5917
Mailing Address - Street 1:13530 MICHIGAN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3574
Mailing Address - Country:US
Mailing Address - Phone:313-945-9800
Mailing Address - Fax:314-667-6915
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:313-945-9800
Practice Address - Fax:314-667-6915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty