Healthcare Provider Details

I. General information

NPI: 1104206978
Provider Name (Legal Business Name): MICHIGAN MEDICAL CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29984 TELEGRAPH RD STE A
SOUTHFIELD MI
48034-1355
US

IV. Provider business mailing address

2601 KINGSTOWNE DR
COMMERCE TWP MI
48390-2712
US

V. Phone/Fax

Practice location:
  • Phone: 248-933-1224
  • Fax:
Mailing address:
  • Phone: 248-933-1224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number4301094678
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ALEX OLKHOVSKY
Title or Position: CHAIRMAN OF THE BOARD OF DIRECTORS
Credential:
Phone: 248-933-1224