Provider Demographics
NPI:1114364346
Name:PRIMESOURCE OF MICHIGAN LLC
Entity Type:Organization
Organization Name:PRIMESOURCE OF MICHIGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-317-0711
Mailing Address - Street 1:2100 E LAKE COOK RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1999
Mailing Address - Country:US
Mailing Address - Phone:800-317-0711
Mailing Address - Fax:877-821-6402
Practice Address - Street 1:2000 TOWN CTR
Practice Address - Street 2:SUITE 1900
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1135
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:877-821-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty