Provider Demographics
NPI:1831480425
Name:FAMILY MEDICAL CENTER OF MICHIGAN, INC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER OF MICHIGAN, INC
Other - Org Name:FAMILY MEDICAL CENTER LENAWEE DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-850-6914
Mailing Address - Street 1:8765 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9583
Mailing Address - Country:US
Mailing Address - Phone:734-847-7380
Mailing Address - Fax:734-850-0520
Practice Address - Street 1:128 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2723
Practice Address - Country:US
Practice Address - Phone:517-266-0651
Practice Address - Fax:517-266-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
231000Medicare Oscar/Certification