Provider Demographics
NPI:1912023458
Name:SPORTS MEDICINE CENTER OF METRO DETROIT PC
Entity Type:Organization
Organization Name:SPORTS MEDICINE CENTER OF METRO DETROIT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TREMONTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-813-0002
Mailing Address - Street 1:5600 CROOKS RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2811
Mailing Address - Country:US
Mailing Address - Phone:248-813-0002
Mailing Address - Fax:248-813-0007
Practice Address - Street 1:5600 CROOKS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2811
Practice Address - Country:US
Practice Address - Phone:248-813-0002
Practice Address - Fax:248-813-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJC039731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1741033Medicaid
MI0819040002Medicare NSC
MIB45122Medicare UPIN
MI0N14320Medicare PIN