Provider Demographics
NPI:1144261488
Name:EXTENDED CARE MEDICAL ASSOC. PC
Entity type:Organization
Organization Name:EXTENDED CARE MEDICAL ASSOC. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:HAROLD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-681-1963
Mailing Address - Street 1:PO BOX 251642
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-1642
Mailing Address - Country:US
Mailing Address - Phone:248-681-1963
Mailing Address - Fax:248-681-3524
Practice Address - Street 1:4748 S KNOLL CT
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2520
Practice Address - Country:US
Practice Address - Phone:248-681-1963
Practice Address - Fax:248-681-3524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH005640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1704147Medicaid
MI5633702Medicare ID - Type Unspecified
MIE25492Medicare UPIN