Healthcare Provider Details

I. General information

NPI: 1497279020
Provider Name (Legal Business Name): MOLINA MEDICAL GROUP OF MICHIGAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SCHAEFER RD
DEARBORN MI
48126-3655
US

IV. Provider business mailing address

4700 SCHAEFER RD
DEARBORN MI
48126-3655
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-2600
  • Fax: 313-581-0228
Mailing address:
  • Phone: 313-581-2600
  • Fax: 313-581-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: J MARIO MOLINA
Title or Position: OWNER
Credential: MD
Phone: 562-499-6191