Provider Demographics
NPI:1649329913
Name:DR. REGINALD EBURUCHE, MD PLC
Entity type:Organization
Organization Name:DR. REGINALD EBURUCHE, MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IGWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-440-6090
Mailing Address - Street 1:23999 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2528
Mailing Address - Country:US
Mailing Address - Phone:248-440-6090
Mailing Address - Fax:248-440-6094
Practice Address - Street 1:23999 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 114
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2528
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:2007-01-09
Last Update Date:2020-08-22
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
MI4707732Medicaid
MII26374Medicare UPIN
MI0P12430Medicare ID - Type Unspecified