MEDICARE: AZ MEDICAL SERVICES MANAGEMENT LLC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1669788121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZ MEDICAL SERVICES MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	PO BOX 40420
Second Line	:
City	:	REDFORD
State	:	MI
Zip	:	48240-0420
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7405 PURITAN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48238-1207
Country	:	US
Telephone Number	:	313-862-8050
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. JERRY OMAR
Credential	:
Telephone Number	:	313-862-8050

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	08/23/2010

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