Provider Demographics
NPI:1972781359
Name:ADVANCED CARE MEDICAL CENTER
Entity Type:Organization
Organization Name:ADVANCED CARE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-728-5220
Mailing Address - Street 1:20524 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3243
Mailing Address - Country:US
Mailing Address - Phone:313-271-6660
Mailing Address - Fax:313-271-9572
Practice Address - Street 1:849 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3690
Practice Address - Country:US
Practice Address - Phone:734-728-5220
Practice Address - Fax:734-728-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H21822OtherBCBSM
MI0N28080Medicare PIN