Provider Demographics
NPI:1407942394
Name:PERRY MLK MEDICAL CENTER P.C.
Entity Type:Organization
Organization Name:PERRY MLK MEDICAL CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SWILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-338-2793
Mailing Address - Street 1:673 MARTIN LUTHER KING JR BLVD N
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1627
Mailing Address - Country:US
Mailing Address - Phone:248-338-2793
Mailing Address - Fax:
Practice Address - Street 1:673 MARTIN LUTHER KING JR BLVD N
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1627
Practice Address - Country:US
Practice Address - Phone:248-338-2793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBS010362208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0856308604OtherBCBS OF MI
MI000000001401OtherCAPE HEALTH PLAN
MI114402195Medicaid
MI132616OtherCARE CHOICES
MI0856308604OtherBCBS OF MI
MI114402195Medicaid