=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114046877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24420 GRATIOT AVE
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-778-7575
-----------------------------------------------------
Fax | 586-778-7698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24420 GRATIOT AVRENUE
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-778-7575
-----------------------------------------------------
Fax | 586-778-7698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT TAM
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 586-778-7575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5300
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------