Provider Demographics
NPI:1336625540
Name:VMD PRIMARY PROVIDERS EASTERN MICHIGAN, PC
Entity Type:Organization
Organization Name:VMD PRIMARY PROVIDERS EASTERN MICHIGAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBAS
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:312-465-7898
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5200
Mailing Address - Country:US
Mailing Address - Phone:312-465-7900
Mailing Address - Fax:
Practice Address - Street 1:27275 HAGGERTY RD STE 500
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3635
Practice Address - Country:US
Practice Address - Phone:312-465-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid