Provider Demographics
NPI:1760538821
Name:MICHIGAN INSTITUTE OF MEDICINE PC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE OF MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-563-3332
Mailing Address - Street 1:38525 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1012
Mailing Address - Country:US
Mailing Address - Phone:734-542-5512
Mailing Address - Fax:734-542-3115
Practice Address - Street 1:38525 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1012
Practice Address - Country:US
Practice Address - Phone:734-542-5512
Practice Address - Fax:734-542-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108225041OtherBLUE SHIELD
MD4905908 -10Medicaid
MI110H225041OtherBCBS
MI0N95470Medicare PIN
B45903Medicare UPIN