Provider Demographics
NPI:1972375863
Name:MICHIGAN INSTITUTE OF UROLOGY, PC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE OF UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:130 TOWN CENTER DR STE 203
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1744
Practice Address - Country:US
Practice Address - Phone:947-999-8244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies