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General NPI Number Information
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NPI Number | 1174632087
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Entity Type | Organization
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Legal Business Name | VANDYKE MEDICAL CLINIC MANAGEMENT CORP
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 12/01/2015
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Provider Practice Location Address
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Address Line | 19431 VAN DYKE ST
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City | DETROIT
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State | MI
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Zip | 48234-3323
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Country | US
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Telephone | 313-893-2010
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Fax | 313-893-3308
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Provider Business Mailing Address
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Address Line | 19431 VAN DYKE ST
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City | DETROIT
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State | MI
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Zip | 48234-3323
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Country | US
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Telephone | 313-893-2010
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Fax | 313-893-3308
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ERNEST A MULLEN
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Credential | M.D.
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Telephone | 313-893-2010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 4301081357
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License Number State | MI
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