Provider Demographics
NPI:1811467657
Name:MEDICINE MAN MEDICAL, PLLC
Entity type:Organization
Organization Name:MEDICINE MAN MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:317-691-1824
Mailing Address - Street 1:25130 SOUTHFIELD RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1900
Mailing Address - Country:US
Mailing Address - Phone:317-691-1824
Mailing Address - Fax:
Practice Address - Street 1:25130 SOUTHFIELD ROAD
Practice Address - Street 2:SUITE #210
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:317-691-1824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty