Provider Demographics
NPI:1407392970
Name:FAMILY MEDICAL CENTER OF MICHIGAN,INC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER OF MICHIGAN,INC
Other - Org Name:FAMILY MEDICAL CENTER OF MI-SOUTHGATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-850-6914
Mailing Address - Street 1:8765 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9583
Mailing Address - Country:US
Mailing Address - Phone:734-847-3802
Mailing Address - Fax:734-850-0520
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-654-2169
Practice Address - Fax:734-654-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH19CS02960261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231107Medicare Oscar/Certification