Healthcare Provider Details

I. General information

NPI: 1144421959
Provider Name (Legal Business Name): CAPAC MEDICAL CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 CAPAC RD
MUSSEY MI
48014-3108
US

IV. Provider business mailing address

4316 CAPAC RD
MUSSEY MI
48014-3108
US

V. Phone/Fax

Practice location:
  • Phone: 810-395-4375
  • Fax:
Mailing address:
  • Phone: 810-395-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPM406642
License Number StateMI

VIII. Authorized Official

Name: PHILLIP MATICH
Title or Position: PRESIDENT
Credential: M D
Phone: 810-395-4375