Provider Demographics
NPI:1952680878
Name:MED SOURCE SERVICES
Entity Type:Organization
Organization Name:MED SOURCE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-746-0882
Mailing Address - Street 1:24901 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2203
Mailing Address - Country:US
Mailing Address - Phone:248-748-0882
Mailing Address - Fax:248-357-2380
Practice Address - Street 1:24901 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 205
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2203
Practice Address - Country:US
Practice Address - Phone:248-748-0882
Practice Address - Fax:248-357-2380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty