Provider Demographics
NPI:1811962376
Name:M-15 FAMILY MEDICAL CENTER P C
Entity type:Organization
Organization Name:M-15 FAMILY MEDICAL CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAYLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-625-5885
Mailing Address - Street 1:7736 ORTONVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4483
Mailing Address - Country:US
Mailing Address - Phone:248-625-5885
Mailing Address - Fax:248-625-6794
Practice Address - Street 1:7736 ORTONVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4483
Practice Address - Country:US
Practice Address - Phone:248-625-5885
Practice Address - Fax:248-625-6794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5630195OtherBCBS
MI080127004OtherMEDICARE RAILROAD
MIOP32990Medicare PIN
MI080127004OtherMEDICARE RAILROAD