MEDICARE: PROACTIVE MD MI 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1255106498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE MD MI PLLC

Provider Business Mailing Address
First Line	:	124 ALLAWOOD CT
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-6207
Country	:	US
Telephone Number	:	864-501-0751
Fax Number	:

Provider Business Practice Location Address
First Line	:	164 MCLEAN
Second Line	:
City	:	BRUCE TWP
State	:	MI
Zip	:	48065-4919
Country	:	US
Telephone Number	:	864-501-0751
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS PROJECT COORDINATOR
Name	:	DARIA JONES
Credential	:
Telephone Number	:	864-501-0751

Provider Enumeration Date	:	11/17/2023
Last Update Date	:	12/22/2023

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