Provider Demographics
NPI:1235109786
Name:AFFILIATED MEDICAL OF DEARBORN P.L.L.C.
Entity Type:Organization
Organization Name:AFFILIATED MEDICAL OF DEARBORN P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:313-562-6607
Mailing Address - Street 1:2200 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3058
Mailing Address - Country:US
Mailing Address - Phone:313-562-6607
Mailing Address - Fax:313-562-5851
Practice Address - Street 1:2200 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3058
Practice Address - Country:US
Practice Address - Phone:313-562-6607
Practice Address - Fax:313-562-5851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION54150Medicare ID - Type Unspecified