Healthcare Provider Details

I. General information

NPI: 1295816833
Provider Name (Legal Business Name): BICOUNTY MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13355 E 10 MILE RD
WARREN MI
48089-2048
US

IV. Provider business mailing address

PO BOX 673915
DETROIT MI
48267-3671
US

V. Phone/Fax

Practice location:
  • Phone: 586-759-7510
  • Fax: 586-759-7791
Mailing address:
  • Phone: 586-759-7510
  • Fax: 586-759-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BETTY DAVENPORT
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 810-720-5715