Provider Demographics
NPI:1366509523
Name:CAPAC MEDICAL CENTER PC
Entity Type:Organization
Organization Name:CAPAC MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:MILAN
Authorized Official - Last Name:MATICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-395-4375
Mailing Address - Street 1:4316 CAPAC ROAD
Mailing Address - Street 2:
Mailing Address - City:CAPAC
Mailing Address - State:MI
Mailing Address - Zip Code:48014
Mailing Address - Country:US
Mailing Address - Phone:810-395-4375
Mailing Address - Fax:810-395-4238
Practice Address - Street 1:4316 CAPAC ROAD
Practice Address - Street 2:
Practice Address - City:CAPAC
Practice Address - State:MI
Practice Address - Zip Code:48014
Practice Address - Country:US
Practice Address - Phone:810-395-4375
Practice Address - Fax:810-395-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPM 406642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1909485Medicaid
MI0G46043Medicare ID - Type Unspecified
MI1909485Medicaid