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General NPI Number Information
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NPI Number | 1891307443
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Entity Type | Organization
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Legal Business Name | PARK PLACE FAMILY PRACTICE & INTERNAL MEDICINE
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Dates
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Enumeration Date | 08/17/2020
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Last Update Date | 07/21/2021
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Provider Practice Location Address
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Address Line | 12701 TELEGRAPH RD STE 103
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City | TAYLOR
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State | MI
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Zip | 48180-4087
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Country | US
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Telephone | 734-374-0500
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Fax | 734-374-2415
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Provider Business Mailing Address
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Address Line | 12701 TELEGRAPH RD STE 103
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City | TAYLOR
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State | MI
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Zip | 48180-4087
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Country | US
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Telephone | 734-374-0500
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Fax | 734-374-2415
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Authorized Official
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Title or Position | OFFICE ADMIN
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Name | SUSAN GOSWAMI
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Credential |
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Telephone | 734-374-0500
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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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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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