Provider Demographics
NPI:1013928035
Name:DEARBORN FAMILY CLINIC, P.C.
Entity Type:Organization
Organization Name:DEARBORN FAMILY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-6566
Mailing Address - Street 1:3133 S TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3472
Mailing Address - Country:US
Mailing Address - Phone:313-565-6566
Mailing Address - Fax:313-561-5554
Practice Address - Street 1:3133 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3472
Practice Address - Country:US
Practice Address - Phone:313-565-6566
Practice Address - Fax:313-561-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHW007561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4622742Medicaid
MI1387925Medicaid
MI4622742Medicaid
MI0Q26025Medicare ID - Type UnspecifiedDR HOWARD WRIGHT
MI1387925Medicaid
MII09229Medicare UPIN