Provider Demographics
NPI:1982826467
Name:CHILDRENS AND FAMILY MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:CHILDRENS AND FAMILY MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-386-1500
Mailing Address - Street 1:8542 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1310
Mailing Address - Country:US
Mailing Address - Phone:800-827-3797
Mailing Address - Fax:248-553-2108
Practice Address - Street 1:8209 ALLEN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1401
Practice Address - Country:US
Practice Address - Phone:313-386-1500
Practice Address - Fax:313-386-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P20400Medicare ID - Type Unspecified