Provider Demographics
NPI:1346432184
Name:PAVILION FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:PAVILION FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-423-0700
Mailing Address - Street 1:1547 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5315
Mailing Address - Country:US
Mailing Address - Phone:248-423-0700
Mailing Address - Fax:248-423-0707
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:SUITE 195
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-423-0700
Practice Address - Fax:248-423-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization