Healthcare Provider Details

I. General information

NPI: 1548347206
Provider Name (Legal Business Name): GROUP MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 CARPENTER ST STE 111
HAMTRAMCK MI
48212-9802
US

IV. Provider business mailing address

27900 BERKSHIRE DR
SOUTHFIELD MI
48076-4957
US

V. Phone/Fax

Practice location:
  • Phone: 313-893-8314
  • Fax: 313-893-7532
Mailing address:
  • Phone: 313-893-8314
  • Fax: 313-893-7532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number4301063912
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301063912
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301063912
License Number StateMI

VIII. Authorized Official

Name: DR. OBIOMA S AGOMUOH
Title or Position: OWNER
Credential: M.D.
Phone: 313-893-8314