MEDICARE: QMJ MEDICAL CENTER PC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1417765173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QMJ MEDICAL CENTER PC

Provider Business Mailing Address
First Line	:	49902 TAHOE WAY
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-4483
Country	:	US
Telephone Number	:	248-787-1137
Fax Number	:	248-962-3496

Provider Business Practice Location Address
First Line	:	26237 SOUTHFIELD RD
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-4546
Country	:	US
Telephone Number	:	248-945-1962
Fax Number	:	248-945-1963

Authorized Official
Title or Position	:	BILLER
Name	:	MRS. PRITI PADAMANABHA SHETTY
Credential	:
Telephone Number	:	248-787-1137

Provider Enumeration Date	:	12/26/2024
Last Update Date	:	12/26/2024

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