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General NPI Number Information
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NPI Number | 1134361702
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Entity Type | Organization
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Legal Business Name | CITY MED CLINIC LLC
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Dates
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Enumeration Date | 03/29/2009
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Last Update Date | 03/29/2009
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Provider Practice Location Address
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Address Line | 11190 GRATIOT AVE STE A
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City | DETROIT
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State | MI
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Zip | 48213-1334
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Country | US
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Telephone | 248-996-5025
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Fax |
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Provider Business Mailing Address
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Address Line | 28930 GREENING ST
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-2985
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Country | US
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Telephone | 248-996-5025
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SAMEER SHRIRAM BHAGWAT
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Credential |
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Telephone | 248-996-5025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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