Provider Demographics
NPI:1104206978
Name:MICHIGAN MEDICAL CLINICS
Entity Type:Organization
Organization Name:MICHIGAN MEDICAL CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD OF DIRECTORS
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:OLKHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-933-1224
Mailing Address - Street 1:2601 KINGSTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2712
Mailing Address - Country:US
Mailing Address - Phone:248-933-1224
Mailing Address - Fax:
Practice Address - Street 1:29984 TELEGRAPH RD
Practice Address - Street 2:STE A
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1355
Practice Address - Country:US
Practice Address - Phone:248-933-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094678204C00000X
207PE0005X, 207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty