Provider Demographics
NPI:1649302035
Name:ECOLOGICAL INTERNAL MEDICINE, PLLC
Entity type:Organization
Organization Name:ECOLOGICAL INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-213-4901
Mailing Address - Street 1:1955 PAULINE BLVD
Mailing Address - Street 2:SUITE 100D
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5003
Mailing Address - Country:US
Mailing Address - Phone:734-213-4901
Mailing Address - Fax:734-213-4910
Practice Address - Street 1:1955 PAULINE BLVD
Practice Address - Street 2:SUITE 100D
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5003
Practice Address - Country:US
Practice Address - Phone:734-213-4901
Practice Address - Fax:734-213-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014751261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII09516Medicare UPIN