Provider Demographics
NPI:1497279020
Name:MOLINA MEDICAL GROUP OF MICHIGAN, PC
Entity Type:Organization
Organization Name:MOLINA MEDICAL GROUP OF MICHIGAN, PC
Other - Org Name:AVALON HEALTH CENTER-URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MARIO
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-499-6191
Mailing Address - Street 1:4700 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3655
Mailing Address - Country:US
Mailing Address - Phone:313-581-2600
Mailing Address - Fax:313-581-0228
Practice Address - Street 1:4700 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3655
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty