Provider Demographics
NPI:1720059660
Name:NORTHSIDE MEDICAL CLINIC MANAGEMENT COMPANY
Entity Type:Organization
Organization Name:NORTHSIDE MEDICAL CLINIC MANAGEMENT COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-273-1200
Mailing Address - Street 1:14001 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2101
Mailing Address - Country:US
Mailing Address - Phone:313-273-1200
Mailing Address - Fax:313-273-8130
Practice Address - Street 1:14001 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2101
Practice Address - Country:US
Practice Address - Phone:313-273-1200
Practice Address - Fax:313-273-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N14570Medicare PIN