Provider Demographics
NPI:1659321321
Name:MICHIGAN HEART PC
Entity type:Organization
Organization Name:MICHIGAN HEART PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCALLISTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:734-712-8000
Mailing Address - Street 1:5325 ELLIOTT DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8633
Mailing Address - Country:US
Mailing Address - Phone:734-712-8000
Mailing Address - Fax:734-712-4319
Practice Address - Street 1:5325 ELLIOTT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8000
Practice Address - Fax:734-712-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207RC0000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H16128Medicare PIN
MI0M07480Medicare PIN
MI0P15340Medicare PIN