Healthcare Provider Details

I. General information

NPI: 1346690757
Provider Name (Legal Business Name): DETROIT 74TH MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 LORAIN AVE
CLEVELAND OH
44102-3351
US

IV. Provider business mailing address

4805 LORAIN AVE
CLEVELAND OH
44102-3351
US

V. Phone/Fax

Practice location:
  • Phone: 216-631-5749
  • Fax: 216-631-5870
Mailing address:
  • Phone: 216-631-5749
  • Fax: 216-631-5870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BETTY G TURCIOS
Title or Position: OWNER
Credential:
Phone: 216-631-5749