Provider Demographics
NPI:1801925201
Name:MEDICAL GROUP PRACTICE, P.C.
Entity type:Organization
Organization Name:MEDICAL GROUP PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-425-0500
Mailing Address - Street 1:9460 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3059
Mailing Address - Country:US
Mailing Address - Phone:734-425-0500
Mailing Address - Fax:734-425-1002
Practice Address - Street 1:9460 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3059
Practice Address - Country:US
Practice Address - Phone:734-425-0500
Practice Address - Fax:734-425-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101004910207Q00000X
MI5101005940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q245094011Medicare ID - Type UnspecifiedGROUP #
MIE33278Medicare UPIN
MIE31645Medicare UPIN