Provider Demographics
NPI:1932459468
Name:PHYSIQUE MEDICAL WELLNES CLINIC PLLC
Entity Type:Organization
Organization Name:PHYSIQUE MEDICAL WELLNES CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-BC
Authorized Official - Phone:248-908-9079
Mailing Address - Street 1:23815 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-7738
Mailing Address - Country:US
Mailing Address - Phone:248-208-9079
Mailing Address - Fax:248-208-9079
Practice Address - Street 1:23815 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7738
Practice Address - Country:US
Practice Address - Phone:248-208-9079
Practice Address - Fax:248-208-9079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty