Healthcare Provider Details

I. General information

NPI: 1427208537
Provider Name (Legal Business Name): PRIME GARDEN CITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35600 CENTRAL CITY PKWY SUITE 104
WESTLAND MI
48185-2046
US

IV. Provider business mailing address

35600 CENTRAL CITY PKWY SUITE 104
WESTLAND MI
48185-2046
US

V. Phone/Fax

Practice location:
  • Phone: 734-261-3778
  • Fax: 734-524-0981
Mailing address:
  • Phone: 734-261-3778
  • Fax: 734-524-0981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN F MAGNUSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 734-458-4490