MEDICARE: METRO MEDICAL OF DEARBORN 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	207QA0505X	Adult Medicine Physician	5101005442	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1386970838	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1477970457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METRO MEDICAL OF DEARBORN PC

Provider Business Mailing Address
First Line	:	2220 N TELEGRAPH RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-2213
Country	:	US
Telephone Number	:	313-563-7878
Fax Number	:	313-563-8443

Provider Business Practice Location Address
First Line	:	2220 N TELEGRAPH RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-2213
Country	:	US
Telephone Number	:	313-563-7878
Fax Number	:	313-563-8443

Authorized Official
Title or Position	:	MANAGER
Name	:	CHRIS STANLEY
Credential	:
Telephone Number	:	313-563-7878

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	06/25/2014

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