Provider Demographics
NPI:1619994688
Name:ADVANCED CARE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ADVANCED CARE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-348-9900
Mailing Address - Street 1:20524 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3243
Mailing Address - Country:US
Mailing Address - Phone:248-348-9900
Mailing Address - Fax:248-347-3003
Practice Address - Street 1:27780 NOVI RAOD
Practice Address - Street 2:SUITE 104
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-348-9900
Practice Address - Fax:248-347-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBCBSMOther080H218220
MI=========OtherTAX ID
MIBCBSMOther080H218220