=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174286017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT PHYSICIANS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2021
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5032 ROCHESTER RD STE 200
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-250-9029
-----------------------------------------------------
Fax | 248-250-9733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 E MAPLE ST
-----------------------------------------------------
City | HOLLY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48442-1755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-820-1712
-----------------------------------------------------
Fax | 248-469-0966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | OLIVIA PASS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-820-1712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------