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General NPI Number Information
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NPI Number | 1497960447
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Entity Type | Organization
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Legal Business Name | PHYSICIANS RESOURCES NETWORK, PC
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Dates
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Enumeration Date | 05/13/2007
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 7795 ELIZABETH LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48327-3603
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Country | US
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Telephone | 248-698-3129
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Fax | 248-698-3129
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Provider Business Mailing Address
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Address Line | 7795 ELIZABETH LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48327-3603
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Country | US
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Telephone | 248-698-3129
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Fax | 248-698-3129
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Authorized Official
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Title or Position | CEO, CFO, CHAIRMAN OF THE BOARD
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Name | DR. WALLY SHERMAN MAHAR
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Credential | M.D.
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Telephone | 248-698-3129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 4301030215
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License Number State | MI
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