MEDICARE: PLYMOUTH CANTON FAMILY HEALTH CARE 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	207Q00000X	Family Medicine Physician	JB010278	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	:	1518095850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLYMOUTH CANTON FAMILY HEALTH CARE PC

Provider Business Mailing Address
First Line	:	PO BOX 700890
Second Line	:
City	:	PLYMOUTH
State	:	MI
Zip	:	48170-0955
Country	:	US
Telephone Number	:	734-453-5360
Fax Number	:	734-453-5380

Provider Business Practice Location Address
First Line	:	44633 JOY RD STE 100
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-1731
Country	:	US
Telephone Number	:	734-453-5360
Fax Number	:	734-453-5380

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MR. JEROME BEKKER
Credential	:	DO
Telephone Number	:	734-453-5360

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	02/17/2011

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