Provider Demographics
NPI:1851715585
Name:CORONDAN MEDICAL PC CORP
Entity Type:Organization
Organization Name:CORONDAN MEDICAL PC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:I
Authorized Official - Last Name:CORONDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-837-9419
Mailing Address - Street 1:14050 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-5765
Mailing Address - Country:US
Mailing Address - Phone:586-920-2249
Mailing Address - Fax:
Practice Address - Street 1:14050 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-5765
Practice Address - Country:US
Practice Address - Phone:586-920-2249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059864261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI321078Medicaid
MIG21275Medicare UPIN
MIOM19910Medicare PIN