Healthcare Provider Details

I. General information

NPI: 1518095850
Provider Name (Legal Business Name): PLYMOUTH CANTON FAMILY HEALTH CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44633 JOY RD STE 100
CANTON MI
48187-1731
US

IV. Provider business mailing address

PO BOX 700890
PLYMOUTH MI
48170-0955
US

V. Phone/Fax

Practice location:
  • Phone: 734-453-5360
  • Fax: 734-453-5380
Mailing address:
  • Phone: 734-453-5360
  • Fax: 734-453-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJB010278
License Number StateMI

VIII. Authorized Official

Name: MR. JEROME BEKKER
Title or Position: PHYSICIAN
Credential: DO
Phone: 734-453-5360