Provider Demographics
NPI:1275301632
Name:MICHIGAN INSTITUTE OF UROLOGY PC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE OF UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:2300 GENOA BUSINESS PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7368
Practice Address - Country:US
Practice Address - Phone:586-771-4820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty