Healthcare Provider Details

I. General information

NPI: 1912619289
Provider Name (Legal Business Name): SOUTHFIELD ESSENTIAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24567 NORTHWESTERN HWY STE 509
SOUTHFIELD MI
48075-2421
US

IV. Provider business mailing address

24567 NORTHWESTERN HWY STE 509
SOUTHFIELD MI
48075-2421
US

V. Phone/Fax

Practice location:
  • Phone: 248-726-0618
  • Fax:
Mailing address:
  • Phone: 248-726-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY CARTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-726-0618