Provider Demographics
NPI: | 1467759928 |
---|---|
Name: | PERSONALIZED MEDICAL CARE ASSOC P C |
Entity Type: | Organization |
Organization Name: | PERSONALIZED MEDICAL CARE ASSOC P C |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | VICTORIA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DOOLEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 248-946-4905 |
Mailing Address - Street 1: | 21580 NOVI RD |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | NOVI |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48375-5600 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-946-4905 |
Mailing Address - Fax: | 888-502-9335 |
Practice Address - Street 1: | 21580 NOVI RD |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | NOVI |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48375-5600 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-946-4905 |
Practice Address - Fax: | 888-502-9335 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-02-18 |
Last Update Date: | 2012-01-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301090829 | 261Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |