Provider Demographics
NPI:1851688428
Name:MEDISTAT
Entity Type:Organization
Organization Name:MEDISTAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARAMEDIC/MEDICAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORTHIA
Authorized Official - Middle Name:CAROLYN
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:CCEMT-P
Authorized Official - Phone:734-587-2217
Mailing Address - Street 1:8511 OAKVILLE WALTZ RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-9504
Mailing Address - Country:US
Mailing Address - Phone:248-914-6015
Mailing Address - Fax:
Practice Address - Street 1:8511 OAKVILLE WALTZ RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-9504
Practice Address - Country:US
Practice Address - Phone:248-914-6015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3201006614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty