Provider Demographics
NPI:1578702205
Name:BERRIOS ANTUNA FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:BERRIOS ANTUNA FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERRIOS-ANTUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-574-9266
Mailing Address - Street 1:6224 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-2953
Mailing Address - Country:US
Mailing Address - Phone:313-574-9266
Mailing Address - Fax:
Practice Address - Street 1:6224 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-2953
Practice Address - Country:US
Practice Address - Phone:313-574-9266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088825261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301088825OtherLICENSE NUMBER
N98500013Medicare PIN