Provider Demographics
NPI:1235281916
Name:PRIMECARE OF NOVI PLLC
Entity Type:Organization
Organization Name:PRIMECARE OF NOVI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-426-7200
Mailing Address - Street 1:39555 WEST TEN MILE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2950
Mailing Address - Country:US
Mailing Address - Phone:248-426-7200
Mailing Address - Fax:248-426-7335
Practice Address - Street 1:39555 WEST TEN MILE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2950
Practice Address - Country:US
Practice Address - Phone:248-426-7200
Practice Address - Fax:248-426-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F316970OtherBLUE CROSS BLUE SHIELD MI
MI0F316970OtherBLUE CROSS BLUE SHIELD MI