Provider Demographics
NPI:1194862656
Name:MAPLE MILLENNIUM MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:MAPLE MILLENNIUM MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAMOD
Authorized Official - Middle Name:
Authorized Official - Last Name:KERKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-977-7246
Mailing Address - Street 1:5456 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5110
Mailing Address - Country:US
Mailing Address - Phone:586-977-7246
Mailing Address - Fax:
Practice Address - Street 1:5456 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5110
Practice Address - Country:US
Practice Address - Phone:586-977-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI506851261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23C0001058OtherHEALTH ALLIANCE PLAN
40346OtherBCBS MI
MI23C0001058OtherHEALTH ALLIANCE PLAN