=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386970838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEL-FORD MEDICAL WALKIN CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2009
-----------------------------------------------------
Last Update Date | 10/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 N TELEGRAPH RD
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48128-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-563-4506
-----------------------------------------------------
Fax | 313-563-8443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2220 N TELEGRAPH RD
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48128-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-563-4506
-----------------------------------------------------
Fax | 313-563-8443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. IRWIN MARCUS LUTWIN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 313-563-4506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101005442
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------