Provider Demographics
NPI:1205964012
Name:HOME VISIT MD PLC
Entity type:Organization
Organization Name:HOME VISIT MD PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:EBURUCHE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:248-440-6090
Mailing Address - Street 1:P. O. BOX 250077
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-440-6090
Mailing Address - Fax:248-440-6094
Practice Address - Street 1:26206 W 12 MILE RD
Practice Address - Street 2:STE 302
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8501
Practice Address - Country:US
Practice Address - Phone:248-440-6090
Practice Address - Fax:248-440-6094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI470773210Medicaid
MI0P12430Medicare ID - Type Unspecified
MI470773210Medicaid