MEDICARE: MICHIGAN INSTITUTE OF UROLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1245002138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN INSTITUTE OF UROLOGY, PC

Provider Business Mailing Address
First Line	:	20952 E 12 MILE RD STE 200
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48081-3203
Country	:	US
Telephone Number	:	586-771-4820
Fax Number	:

Provider Business Practice Location Address
First Line	:	19117 ALLEN RD STE A
Second Line	:
City	:	BROWNSTOWN TWP
State	:	MI
Zip	:	48183-1066
Country	:	US
Telephone Number	:	734-676-4040
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	TRACY LEE MCAULEY
Credential	:
Telephone Number	:	586-771-4820

Provider Enumeration Date	:	10/25/2023
Last Update Date	:	01/14/2025

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