Provider Demographics
NPI:1346347523
Name:HOME PHYSICIAN SERVICES PC
Entity Type:Organization
Organization Name:HOME PHYSICIAN SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SONJAI
Authorized Official - Middle Name:
Authorized Official - Last Name:POONPANIJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-743-1099
Mailing Address - Street 1:17520 W 12 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1907
Mailing Address - Country:US
Mailing Address - Phone:248-228-8654
Mailing Address - Fax:248-228-8656
Practice Address - Street 1:17520 W 12 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1907
Practice Address - Country:US
Practice Address - Phone:248-228-8654
Practice Address - Fax:248-228-8656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032562208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P14460Medicare ID - Type Unspecified