Provider Demographics
NPI:1720118037
Name:SOUTHFIELD FAMILY PHYSICIANS, PLLC
Entity Type:Organization
Organization Name:SOUTHFIELD FAMILY PHYSICIANS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GABBANAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:242-353-4777
Mailing Address - Street 1:22972 LAHSER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4408
Mailing Address - Country:US
Mailing Address - Phone:248-353-4777
Mailing Address - Fax:248-353-4235
Practice Address - Street 1:22972 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4408
Practice Address - Country:US
Practice Address - Phone:248-353-4777
Practice Address - Fax:248-353-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMJ034283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080F375520OtherBCBS
MI4102457Medicaid
0M80170001Medicare PIN
MI4102457Medicaid
0M80170Medicare PIN