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General NPI Number Information
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NPI Number | 1053647131
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Entity Type | Organization
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Legal Business Name | MOTOWN RESIDENTIAL PHYSICIAN PLLC
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Dates
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Enumeration Date | 10/26/2009
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Last Update Date | 06/03/2010
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Provider Practice Location Address
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Address Line | 852 CEDARGATE CT
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City | WATERFORD
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State | MI
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Zip | 48328-2606
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Country | US
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Telephone | 248-659-7576
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Fax |
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Provider Business Mailing Address
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Address Line | 852 CEDARGATE CT
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City | WATERFORD
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State | MI
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Zip | 48328-2606
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Country | US
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Telephone | 248-659-7576
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Fax |
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Authorized Official
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Title or Position | BILLING/CREDENTIALING
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Name | LINDA EVANS
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Credential |
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Telephone | 248-476-6385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 023784
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License Number State | MI
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