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General NPI Number Information
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NPI Number | 1629263520
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Entity Type | Organization
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Legal Business Name | WESTERN WAYNE FAMILY PHYSICIANS, PLC
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Dates
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Enumeration Date | 09/13/2007
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Last Update Date | 03/18/2008
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Provider Practice Location Address
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Address Line | 7445 ALLEN RD SUITE 250
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City | ALLEN PARK
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State | MI
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Zip | 48101-1963
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Country | US
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Telephone | 313-386-5500
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Fax | 313-386-3444
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Provider Business Mailing Address
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Address Line | 7445 ALLEN RD SUITE 250
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City | ALLEN PARK
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State | MI
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Zip | 48101-1963
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Country | US
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Telephone | 313-386-5500
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Fax | 313-386-3444
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Authorized Official
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Title or Position | OWNER / SECRETARY
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Name | DR. ROBERT J JACKSON
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Credential | M.D.
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Telephone | 313-386-5500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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