Provider Demographics
NPI:1689956260
Name:PROFESSIONAL HOME DOCTORS
Entity Type:Organization
Organization Name:PROFESSIONAL HOME DOCTORS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-506-9098
Mailing Address - Street 1:3200 GREENFIELD RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1800
Mailing Address - Country:US
Mailing Address - Phone:313-334-6395
Mailing Address - Fax:248-539-4645
Practice Address - Street 1:18444 W. 10MILE ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2626
Practice Address - Country:US
Practice Address - Phone:248-539-4640
Practice Address - Fax:248-539-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44179Medicare UPIN