Provider Demographics
NPI:1497960447
Name:PHYSICIANS RESOURCES NETWORK, PC
Entity Type:Organization
Organization Name:PHYSICIANS RESOURCES NETWORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, CFO, CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLY
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:MAHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-698-3129
Mailing Address - Street 1:7795 ELIZABETH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-3603
Mailing Address - Country:US
Mailing Address - Phone:248-698-3129
Mailing Address - Fax:248-698-3129
Practice Address - Street 1:7795 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-3603
Practice Address - Country:US
Practice Address - Phone:248-698-3129
Practice Address - Fax:248-698-3129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030215174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00575YOtherMICHIGAN CORPORATION ID
MI=========OtherF.E.I.D. (FEDERAL)