Healthcare Provider Details

I. General information

NPI: 1740280676
Provider Name (Legal Business Name): FAMILY & SPORTS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 S MAIN ST
PLYMOUTH MI
48170-2048
US

IV. Provider business mailing address

965 S MAIN ST
PLYMOUTH MI
48170-2048
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-2970
  • Fax: 313-561-0277
Mailing address:
  • Phone: 734-455-2970
  • Fax: 313-561-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberRG008180
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT GORDON
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 734-455-2970