Provider Demographics
NPI:1942539598
Name:TRIPLE T MEDICAL PC
Entity Type:Organization
Organization Name:TRIPLE T MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:313-342-9255
Mailing Address - Street 1:17187 SCHAEFER HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-4132
Mailing Address - Country:US
Mailing Address - Phone:313-342-9255
Mailing Address - Fax:313-342-8489
Practice Address - Street 1:17187 SCHAEFER HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4132
Practice Address - Country:US
Practice Address - Phone:313-342-9255
Practice Address - Fax:313-342-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058406207Q00000X
MI4301068024207R00000X
MI4301053315207R00000X, 208000000X
MI4301066816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500H258510OtherBCBS NP GROUP NUMBER
MI700H258460OtherBCBS GROUP
MI1942539598Medicaid
MI700H258460OtherBCBS GROUP