Provider Demographics
NPI:1518095850
Name:PLYMOUTH CANTON FAMILY HEALTH CARE PC
Entity Type:Organization
Organization Name:PLYMOUTH CANTON FAMILY HEALTH CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:BEKKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-453-5360
Mailing Address - Street 1:PO BOX 700890
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-0955
Mailing Address - Country:US
Mailing Address - Phone:734-453-5360
Mailing Address - Fax:734-453-5380
Practice Address - Street 1:44633 JOY RD STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1731
Practice Address - Country:US
Practice Address - Phone:734-453-5360
Practice Address - Fax:734-453-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB010278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114731255Medicaid
MIF05093Medicare UPIN
MI114731255Medicaid