Provider Demographics
NPI:1154664688
Name:OPDYKE MEDICAL, PLLC
Entity Type:Organization
Organization Name:OPDYKE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:CRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-240-5699
Mailing Address - Street 1:3959 CENTERPOINT PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-3121
Mailing Address - Country:US
Mailing Address - Phone:248-333-2600
Mailing Address - Fax:248-333-3250
Practice Address - Street 1:3959 CENTERPOINT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-3121
Practice Address - Country:US
Practice Address - Phone:248-333-2600
Practice Address - Fax:248-333-3250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2805350Medicaid
MI2805350Medicaid