Provider Demographics
NPI:1205318722
Name:ST. MICHAEL'S INTERNAL MEDICINE PHYSICIANS, PLLC
Entity type:Organization
Organization Name:ST. MICHAEL'S INTERNAL MEDICINE PHYSICIANS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REVARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-217-8405
Mailing Address - Street 1:4448 FORESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4448 FORESTVIEW DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4507
Practice Address - Country:US
Practice Address - Phone:248-217-8405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty