Provider Demographics
NPI:1770819864
Name:MIDWEST FAMILY PRACTICES, PLC
Entity Type:Organization
Organization Name:MIDWEST FAMILY PRACTICES, PLC
Other - Org Name:MIDWEST FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:AWADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-751-2020
Mailing Address - Street 1:12640 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3520
Mailing Address - Country:US
Mailing Address - Phone:586-751-2020
Mailing Address - Fax:586-751-7872
Practice Address - Street 1:12640 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3520
Practice Address - Country:US
Practice Address - Phone:586-751-2020
Practice Address - Fax:586-751-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty