Healthcare Provider Details

I. General information

NPI: 1366509523
Provider Name (Legal Business Name): CAPAC MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 CAPAC ROAD
CAPAC MI
48014
US

IV. Provider business mailing address

4316 CAPAC ROAD
CAPAC MI
48014
US

V. Phone/Fax

Practice location:
  • Phone: 810-395-4375
  • Fax: 810-395-4238
Mailing address:
  • Phone: 810-395-4375
  • Fax: 810-395-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPM 406642
License Number StateMI

VIII. Authorized Official

Name: MR. PHILIP MILAN MATICH
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 810-395-4375