Healthcare Provider Details

I. General information

NPI: 1194864462
Provider Name (Legal Business Name): VANGUARD FAMILY HEALTH CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10809 MACK AVE
DETROIT MI
48214-2119
US

IV. Provider business mailing address

10809 MACK AVE
DETROIT MI
48214-2119
US

V. Phone/Fax

Practice location:
  • Phone: 313-824-1000
  • Fax: 313-824-9000
Mailing address:
  • Phone: 313-824-1000
  • Fax: 313-824-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberJB002247
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMP005908
License Number StateMI

VIII. Authorized Official

Name: MS. LINDA POPOFF
Title or Position: SECRETARY
Credential:
Phone: 313-824-1000