Provider Demographics
NPI:1639105695
Name:SILVER PINE MEDICAL GROUP PLC
Entity Type:Organization
Organization Name:SILVER PINE MEDICAL GROUP PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TANGALOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-726-4823
Mailing Address - Street 1:43455 SCHOENHERR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:586-726-8365
Practice Address - Street 1:43455 SCHOENHERR
Practice Address - Street 2:SUITE 2
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:586-726-8365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID NUMBER
MI=========OtherTAX ID NUMBER