Provider Demographics
NPI:1780853267
Name:RODOLJUB DIMITRIJEVIC MD PC
Entity Type:Organization
Organization Name:RODOLJUB DIMITRIJEVIC MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLJUB
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMITRIJEVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-286-6072
Mailing Address - Street 1:43421 GARFIELD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1133
Mailing Address - Country:US
Mailing Address - Phone:586-286-6072
Mailing Address - Fax:586-286-0900
Practice Address - Street 1:43421 GARFIELD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1133
Practice Address - Country:US
Practice Address - Phone:586-286-6072
Practice Address - Fax:586-286-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD034830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2115483Medicaid
MI2115483Medicaid