Provider Demographics
NPI:1518004084
Name:SOUTH LYON FAMILY PHYSICIANS, PLLC
Entity Type:Organization
Organization Name:SOUTH LYON FAMILY PHYSICIANS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-437-2525
Mailing Address - Street 1:22024 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9410
Mailing Address - Country:US
Mailing Address - Phone:248-437-2525
Mailing Address - Fax:248-437-2526
Practice Address - Street 1:22024 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9410
Practice Address - Country:US
Practice Address - Phone:248-437-2525
Practice Address - Fax:248-437-2526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014989207Q00000X
MI5101005444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101014989OtherSTATE LICENSE
MI5633697OtherBLUE CROSS
MI5101005444OtherSTATE LICENSE
MI5631170OtherBLUE CROSS
MI5101005444OtherSTATE LICENSE
MI5631170OtherBLUE CROSS
MI5101005444OtherSTATE LICENSE
MIG61004Medicare UPIN
MIN94720002Medicare ID - Type UnspecifiedPATRICK R. BRENNAN, D.O.
MI0N94720Medicare ID - Type UnspecifiedMEDICARE GROUP NO.