Provider Demographics
NPI:1396571436
Name:MICHIGAN INSTITUTE OF UROLOGY PC
Entity type:Organization
Organization Name:MICHIGAN INSTITUTE OF UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-7960
Practice Address - Street 1:1121 W HILL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4733
Practice Address - Country:US
Practice Address - Phone:810-232-8888
Practice Address - Fax:810-232-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty