Provider Demographics
NPI:1780706879
Name:PCM MEDICAL SERVICE PC
Entity type:Organization
Organization Name:PCM MEDICAL SERVICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN-MIEZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-485-7511
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT# 256801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:737 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5160
Practice Address - Country:US
Practice Address - Phone:517-485-7511
Practice Address - Fax:517-485-7561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N94240Medicare PIN