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General NPI Number Information
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NPI Number | 1952530883
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Entity Type | Organization
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Legal Business Name | SOUTHEAST MICHIGAN MEDICAL GROUP, PC
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Dates
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Enumeration Date | 07/13/2009
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Last Update Date | 07/13/2009
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Provider Practice Location Address
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Address Line | 16018 S HURON RIVER DR
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City | ROMULUS
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State | MI
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Zip | 48174-3619
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Country | US
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Telephone | 419-343-8537
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Fax | 419-893-3226
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Provider Business Mailing Address
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Address Line | 16018 S HURON RIVER DR
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City | ROMULUS
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State | MI
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Zip | 48174-3619
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Country | US
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Telephone | 419-343-8537
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Fax | 419-893-3226
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Authorized Official
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Title or Position | PRESIDENT
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Name | GLENN VANCE DREGANSKY
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Credential | D.O.
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Telephone | 419-343-8537
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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 | 5101010072
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License Number State | MI
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