Provider Demographics
NPI:1902184963
Name:PRIMARY CHILD AND ADULT RENOWNED EXCELLENCE PC
Entity Type:Organization
Organization Name:PRIMARY CHILD AND ADULT RENOWNED EXCELLENCE PC
Other - Org Name:PRIMARY C A R E PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:S
Authorized Official - Last Name:NAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-709-7800
Mailing Address - Street 1:1315 PORTERS LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0943
Mailing Address - Country:US
Mailing Address - Phone:248-709-7800
Mailing Address - Fax:248-334-8585
Practice Address - Street 1:911 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1934
Practice Address - Country:US
Practice Address - Phone:248-542-3300
Practice Address - Fax:248-542-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty