Provider Demographics
NPI:1467620617
Name:MADISON MEDICAL CENTER PC
Entity Type:Organization
Organization Name:MADISON MEDICAL CENTER PC
Other - Org Name:STERLING MEDICAL LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNABALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-583-8922
Mailing Address - Street 1:30781 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-583-8922
Mailing Address - Fax:248-583-8969
Practice Address - Street 1:13409 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6304
Practice Address - Country:US
Practice Address - Phone:586-977-3900
Practice Address - Fax:586-977-6084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON MEDICAL CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E01180Medicare PIN