Provider Demographics
NPI:1205835931
Name:ARBOR LANE FAMILY PHYSICIANS PLC
Entity Type:Organization
Organization Name:ARBOR LANE FAMILY PHYSICIANS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAZELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-561-0550
Mailing Address - Street 1:8555 N SILVERY LN
Mailing Address - Street 2:SUITE C302
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1379
Mailing Address - Country:US
Mailing Address - Phone:313-561-0550
Mailing Address - Fax:313-561-3646
Practice Address - Street 1:8555 N SILVERY LN
Practice Address - Street 2:SUITE C302
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1379
Practice Address - Country:US
Practice Address - Phone:313-561-0550
Practice Address - Fax:313-561-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGG034127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4492601Medicaid
MI4492586Medicaid
MIA77142Medicare UPIN
MI0N69060Medicare PIN
MI4492586Medicaid