Provider Demographics
NPI:1245244110
Name:DETROIT MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:DETROIT MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX-ABBEY
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINWUMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-491-5400
Mailing Address - Street 1:4059 W . DAVISON
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238
Mailing Address - Country:US
Mailing Address - Phone:313-491-5400
Mailing Address - Fax:313-491-8123
Practice Address - Street 1:4059 W DAVISON
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3262
Practice Address - Country:US
Practice Address - Phone:313-491-5400
Practice Address - Fax:313-491-8123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071164261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4488126Medicaid
MION67340Medicare ID - Type Unspecified
MI4488126Medicaid