Provider Demographics
NPI:1912079211
Name:STERLING HEIGHTS MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:STERLING HEIGHTS MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRZYSIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-939-3020
Mailing Address - Street 1:11600 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-5100
Mailing Address - Country:US
Mailing Address - Phone:586-939-3020
Mailing Address - Fax:586-939-2191
Practice Address - Street 1:11600 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-5100
Practice Address - Country:US
Practice Address - Phone:586-939-3020
Practice Address - Fax:586-939-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDC005678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1324783Medicaid
MI1324792Medicaid
MI1324783Medicaid