Healthcare Provider Details

I. General information

NPI: 1245633411
Provider Name (Legal Business Name): PLATINUM CARE PHYSICIANS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27207 LAHSER RD SUITE 250
SOUTHFIELD MI
48034-2168
US

IV. Provider business mailing address

27207 LAHSER RD SUITE 250
SOUTHFIELD MI
48034-2168
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-3200
  • Fax: 248-967-1387
Mailing address:
  • Phone: 248-967-3200
  • Fax: 248-967-1387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number5101012320
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number5101007369
License Number StateMI

VIII. Authorized Official

Name: AQUARIUS BOUIER
Title or Position: MANAGER
Credential:
Phone: 248-967-3200