Provider Demographics
NPI:1992833990
Name:PLYMOUTH CANTON FAMILY PHYSICIANS PC
Entity Type:Organization
Organization Name:PLYMOUTH CANTON FAMILY PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-453-9500
Mailing Address - Street 1:261 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1637
Mailing Address - Country:US
Mailing Address - Phone:734-453-9500
Mailing Address - Fax:734-453-9501
Practice Address - Street 1:261 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1637
Practice Address - Country:US
Practice Address - Phone:734-453-9500
Practice Address - Fax:734-453-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAR056622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104260527Medicaid
MIF69620Medicare UPIN
MI104260527Medicaid