=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982156790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESIDENTIAL DRS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2016
-----------------------------------------------------
Last Update Date | 10/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25900 GREENFIELD RD 415
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-1292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-281-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25900 GREENFIELD RD 415
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-1292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-281-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. RACHELE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-281-3799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101006874
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------