Provider Demographics
NPI:1891307443
Name:PARK PLACE FAMILY PRACTICE & INTERNAL MEDICINE
Entity Type:Organization
Organization Name:PARK PLACE FAMILY PRACTICE & INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-374-0500
Mailing Address - Street 1:12701 TELEGRAPH RD STE 103
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4087
Mailing Address - Country:US
Mailing Address - Phone:734-374-0500
Mailing Address - Fax:734-374-2415
Practice Address - Street 1:12701 TELEGRAPH RD STE 103
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4087
Practice Address - Country:US
Practice Address - Phone:734-374-0500
Practice Address - Fax:734-374-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH62264OtherBCBSM PIN
MI1891307443Medicaid