MEDICARE: IMHOTEP MEDICAL SERVICES, INC.

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	207Q00000X	Family Medicine Physician	M4301056553	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386767473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMHOTEP MEDICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	5525 GREENWAY ST
Second Line	:	SUITE B - 2
City	:	DETROIT
State	:	MI
Zip	:	48204-2112
Country	:	US
Telephone Number	:	313-701-1187
Fax Number	:	313-931-9113

Provider Business Practice Location Address
First Line	:	5525 GREENWAY ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2112
Country	:	US
Telephone Number	:	313-935-0399
Fax Number	:	313-931-9113

Authorized Official
Title or Position	:	OWNER, PHYSICIAN
Name	:	MS. CONNIE L MITCHELL
Credential	:	M.D.
Telephone Number	:	313-701-1187

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	10/06/2014

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Directions to “IMHOTEP MEDICAL SERVICES, INC. ” Practice Location

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