Healthcare Provider Details

I. General information

NPI: 1841467420
Provider Name (Legal Business Name): DETROIT MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24261 GREENFIELD RD SUITE B
SOUTHFIELD MI
48075-3117
US

IV. Provider business mailing address

24261 GREENFIELD RD SUITE B
SOUTHFIELD MI
48075-3117
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-8151
  • Fax: 248-569-8159
Mailing address:
  • Phone: 248-569-8151
  • Fax: 248-569-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301086699
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301041657
License Number StateMI

VIII. Authorized Official

Name: DR. CARMEN CARDONA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 248-569-8151