Provider Demographics
NPI:1548213572
Name:DETROIT MEDICAL CENTER COOPERATIVE
Entity Type:Organization
Organization Name:DETROIT MEDICAL CENTER COOPERATIVE
Other - Org Name:DMC COOPERATIVE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PELC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-578-2820
Mailing Address - Street 1:DEPT 203401
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:313-578-2820
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N24360OtherMEDICARE
MICB6304Medicare ID - Type UnspecifiedRAILROAD MEDICARE