MEDICARE: CONANT FAMILY CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301073086	MI

General Provider Information

NPI Number	:	1205339306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONANT FAMILY CARE PLLC

Provider Business Mailing Address
First Line	:	3611 CARPENTER ST STE 5
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48212-2784
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3611 CARPENTER ST STE 5
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48212-2784
Country	:	US
Telephone Number	:	917-588-1632
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MASUDA POLI
Credential	:
Telephone Number	:	917-588-1632

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	05/01/2018

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Directions to “CONANT FAMILY CARE PLLC ” Practice Location

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