Provider Demographics
NPI:1437544772
Name:ROYAL OAK MEDICAL CENTER PC
Entity Type:Organization
Organization Name:ROYAL OAK MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-288-9500
Mailing Address - Street 1:5130 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1001
Mailing Address - Country:US
Mailing Address - Phone:248-288-9500
Mailing Address - Fax:248-288-0044
Practice Address - Street 1:5130 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1001
Practice Address - Country:US
Practice Address - Phone:248-288-9500
Practice Address - Fax:248-288-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty