Provider Demographics
NPI:1740447481
Name:MEDICAL DOCTORS OF MICHIGAN, PLLC
Entity type:Organization
Organization Name:MEDICAL DOCTORS OF MICHIGAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVINA
Authorized Official - Middle Name:COVACHA
Authorized Official - Last Name:ROSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-240-0077
Mailing Address - Street 1:5460 DOHERTY ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-3419
Mailing Address - Country:US
Mailing Address - Phone:248-240-0077
Mailing Address - Fax:
Practice Address - Street 1:5460 DOHERTY ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-3419
Practice Address - Country:US
Practice Address - Phone:248-240-0077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034721207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty