Provider Demographics
NPI:1770524639
Name:DETROIT MEDICAL SERVICE PLC
Entity type:Organization
Organization Name:DETROIT MEDICAL SERVICE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:UMA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORREPATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-831-7005
Mailing Address - Street 1:4160 JOHN R ST
Mailing Address - Street 2:SUITE 730
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2020
Mailing Address - Country:US
Mailing Address - Phone:313-831-7005
Mailing Address - Fax:313-831-7002
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 730
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-831-7005
Practice Address - Fax:313-831-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4582263OtherAETNA
MIDR6312OtherRAILROAD MEDICARE GROUP
MIE93374OtherHAP
MI137660OtherCARE CHOICES
MI1770524639Medicaid
MI110H2322130OtherBC GROUP
MI110H242220OtherBC GROUP
MI1108298481OtherBCBS
MI8635261OtherCIGNA
MI137660OtherCARE CHOICES
MI1770524639Medicaid