Provider Demographics
NPI:1770752495
Name:ALPHA AND OMEGA PRIMARY HEALTH CARE INC
Entity type:Organization
Organization Name:ALPHA AND OMEGA PRIMARY HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-342-2576
Mailing Address - Street 1:15865 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15865 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1136
Practice Address - Country:US
Practice Address - Phone:313-342-2576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061729208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316903198Medicaid
MI1316903198Medicaid