Provider Demographics
NPI:1235219403
Name:CRITICAL CARE MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:CRITICAL CARE MEDICINE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PHYSICIANLINX LLC
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-563-3332
Mailing Address - Street 1:3200 GREENFIELD RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1802
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-271-5565
Practice Address - Fax:313-271-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M69960Medicare PIN