Healthcare Provider Details

I. General information

NPI: 1255343836
Provider Name (Legal Business Name): FAMPED PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 PACKARD ST SUITE G
ANN ARBOR MI
48104-6806
US

IV. Provider business mailing address

2515 PACKARD ST SUITE G
ANN ARBOR MI
48104-6806
US

V. Phone/Fax

Practice location:
  • Phone: 734-747-7551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301406564
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301406564
License Number StateMI

VIII. Authorized Official

Name: FRANCIS NWANKWO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 734-747-7551