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General NPI Number Information
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NPI Number | 1740793777
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Entity Type | Organization
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Legal Business Name | MEDICINA URBANA WEST VERNOR PLLC
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Dates
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Enumeration Date | 11/13/2017
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Last Update Date | 05/15/2018
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Provider Practice Location Address
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Address Line | 5700 W VERNOR HWY
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City | DETROIT
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State | MI
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Zip | 48209
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Country | US
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Telephone | 313-586-3066
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Fax | 313-586-3165
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Provider Business Mailing Address
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Address Line | 5700 W VERNOR HWY
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City | DETROIT
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State | MI
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Zip | 48209-2158
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Country | US
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Telephone | 313-586-7481
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Fax | 313-899-7392
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Authorized Official
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Title or Position | MEMBER
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Name | MARK RYAN BEARD
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Credential | DO
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Telephone | 313-281-1362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 5101017883
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License Number State | MI
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