Provider Demographics
NPI:1609435056
Name:SELECT MEDICAL GROUP OF MICHIGAN PLLC
Entity Type:Organization
Organization Name:SELECT MEDICAL GROUP OF MICHIGAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-307-7781
Mailing Address - Street 1:23350 GREENFIELD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2496
Mailing Address - Country:US
Mailing Address - Phone:248-307-7781
Mailing Address - Fax:
Practice Address - Street 1:23350 GREENFIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2496
Practice Address - Country:US
Practice Address - Phone:248-307-7781
Practice Address - Fax:248-302-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty