Provider Demographics
NPI:1013350404
Name:PREMIER MEDICINE OF CANTON PC
Entity Type:Organization
Organization Name:PREMIER MEDICINE OF CANTON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARAE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-454-5454
Mailing Address - Street 1:5958 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2765
Mailing Address - Country:US
Mailing Address - Phone:734-454-5454
Mailing Address - Fax:
Practice Address - Street 1:5958 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2765
Practice Address - Country:US
Practice Address - Phone:734-454-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty