Provider Demographics
NPI:1912044611
Name:HAMPTON MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:HAMPTON MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:GILBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-771-0290
Mailing Address - Street 1:30550 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-1528
Mailing Address - Country:US
Mailing Address - Phone:586-771-0290
Mailing Address - Fax:586-771-5450
Practice Address - Street 1:30550 UTICA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-1528
Practice Address - Country:US
Practice Address - Phone:586-771-0290
Practice Address - Fax:586-771-5450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007447207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06135Medicare ID - Type Unspecified
MIE25559Medicare UPIN