Provider Demographics
NPI:1225137649
Name:NORTHVILLE FAMILY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:NORTHVILLE FAMILY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-348-2442
Mailing Address - Street 1:42931 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2277
Mailing Address - Country:US
Mailing Address - Phone:248-348-2442
Mailing Address - Fax:
Practice Address - Street 1:42931 7 MILE RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2277
Practice Address - Country:US
Practice Address - Phone:248-348-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H219120OtherBCBSM
MI700H219120OtherBCBSM