Provider Demographics
NPI:1326244450
Name:CONANT MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:CONANT MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VERTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-806-5977
Mailing Address - Street 1:25529 VAN DYKE AVE
Mailing Address - Street 2:SUITEA
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1848
Mailing Address - Country:US
Mailing Address - Phone:586-806-5977
Mailing Address - Fax:586-806-5985
Practice Address - Street 1:25529 VAN DYKE AVE
Practice Address - Street 2:SUITEA
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1848
Practice Address - Country:US
Practice Address - Phone:586-806-5977
Practice Address - Fax:586-806-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059824207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4425780Medicaid
MI4425780Medicaid
MI0N87130Medicare PIN