MEDICARE: M-15 FAMILY MEDICAL CENTER P C

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	5101011488	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080127004	OTHER	MI	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5630195	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1811962376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M-15 FAMILY MEDICAL CENTER P C

Provider Business Mailing Address
First Line	:	7736 ORTONVILLE RD
Second Line	:	SUITE A
City	:	CLARKSTON
State	:	MI
Zip	:	48348-4483
Country	:	US
Telephone Number	:	248-625-5885
Fax Number	:	248-625-6794

Provider Business Practice Location Address
First Line	:	7736 ORTONVILLE RD
Second Line	:	SUITE A
City	:	CLARKSTON
State	:	MI
Zip	:	48348-4483
Country	:	US
Telephone Number	:	248-625-5885
Fax Number	:	248-625-6794

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LARRY J. BAYLIS
Credential	:	D.O.
Telephone Number	:	248-625-5885

Provider Enumeration Date	:	02/20/2006
Last Update Date	:	07/01/2008

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Directions to “M-15 FAMILY MEDICAL CENTER P C ” Practice Location

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