Healthcare Provider Details

I. General information

NPI: 1174087308
Provider Name (Legal Business Name): FAMILY MEDICAL CENTER OF MICHIGAN,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 TRAVERWOOD DR STE D
ANN ARBOR MI
48105-2197
US

IV. Provider business mailing address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

V. Phone/Fax

Practice location:
  • Phone: 734-850-6903
  • Fax: 734-850-0520
Mailing address:
  • Phone: 734-847-3802
  • Fax: 734-847-3418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ED LARKINS
Title or Position: CEO
Credential:
Phone: 734-850-6914