Healthcare Provider Details

I. General information

NPI: 1821267832
Provider Name (Legal Business Name): EASTLAKE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2008
Last Update Date: 02/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 CHENE ST
DETROIT MI
48207-3979
US

IV. Provider business mailing address

17520 W 12 MILE RD STE 116
SOUTHFIELD MI
48076-1907
US

V. Phone/Fax

Practice location:
  • Phone: 248-747-3425
  • Fax:
Mailing address:
  • Phone: 248-443-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BIANCA FELICIA DOOLEY
Title or Position: PRESIDENT CEO
Credential:
Phone: 248-747-3425