Healthcare Provider Details

I. General information

NPI: 1700866811
Provider Name (Legal Business Name): PHYSICIANS RESIDENTIAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20927 KELLY RD
EASTPOINTE MI
48021-3128
US

IV. Provider business mailing address

20927 KELLY RD
EASTPOINTE MI
48021-3128
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-8801
  • Fax: 586-777-9988
Mailing address:
  • Phone: 586-777-8801
  • Fax: 586-777-9988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301068676
License Number StateMI

VIII. Authorized Official

Name: DR. EDWIN J SOLER-VALCOURT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 586-777-8801