Provider Demographics
NPI:1619985058
Name:PROFESSIONAL MEDICAL CENTER PC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOLE-JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-925-4540
Mailing Address - Street 1:PO BOX 3160
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-0160
Mailing Address - Country:US
Mailing Address - Phone:313-925-4540
Mailing Address - Fax:313-925-0322
Practice Address - Street 1:3956 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1841
Practice Address - Country:US
Practice Address - Phone:313-925-4540
Practice Address - Fax:313-925-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M69920Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER