Provider Demographics
NPI:1801926738
Name:UNION LAKE MEDICAL CENTER PC
Entity type:Organization
Organization Name:UNION LAKE MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-363-7109
Mailing Address - Street 1:1990 UNION LAKE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-2200
Mailing Address - Country:US
Mailing Address - Phone:248-363-7109
Mailing Address - Fax:248-363-7211
Practice Address - Street 1:1990 UNION LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2200
Practice Address - Country:US
Practice Address - Phone:248-363-7109
Practice Address - Fax:248-363-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD060871261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3245750Medicaid
MIOF3649301Medicare ID - Type UnspecifiedMEDICARE
MIG23587Medicare UPIN