Provider Demographics
NPI:1952530883
Name:SOUTHEAST MICHIGAN MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:SOUTHEAST MICHIGAN MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:DREGANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-343-8537
Mailing Address - Street 1:16018 S HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3619
Mailing Address - Country:US
Mailing Address - Phone:419-343-8537
Mailing Address - Fax:419-893-3226
Practice Address - Street 1:16018 S HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-3619
Practice Address - Country:US
Practice Address - Phone:419-343-8537
Practice Address - Fax:419-893-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty