Provider Demographics
NPI:1659370724
Name:ABBOTT MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ABBOTT MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-341-4800
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:313-341-4800
Mailing Address - Fax:313-341-4848
Practice Address - Street 1:19830 JAMES COUZENS FWY
Practice Address - Street 2:SUITE B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1938
Practice Address - Country:US
Practice Address - Phone:313-341-4800
Practice Address - Fax:313-341-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4277758Medicaid
MI4583949Medicaid
MI110H238930OtherBC GROUP
MI110H238930OtherBCN GROUP
MI614199100OtherDEPT OF LABOR
MI110H238930OtherBCN GROUP
MI4583949Medicaid