Healthcare Provider Details

I. General information

NPI: 1275920084
Provider Name (Legal Business Name): EPIC PRIMARY CARE III PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 MONROE ST STE 208
DEARBORN MI
48124-2950
US

IV. Provider business mailing address

390 ENTERPRISE CT SUITE 103
BLOOMFIELD HILLS MI
48302-0320
US

V. Phone/Fax

Practice location:
  • Phone: 248-336-4000
  • Fax: 248-336-9137
Mailing address:
  • Phone: 248-336-4000
  • Fax: 248-336-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TED NAMAN
Title or Position: MEMBER
Credential: MD
Phone: 248-336-4000