MEDICARE: CHERRY HILL VILLAGE FAMILY MEDICINE

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

General Provider Information

NPI Number	:	1629348792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY HILL VILLAGE FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	49796 TAFT LN
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-6722
Country	:	US
Telephone Number	:	734-645-9228
Fax Number	:

Provider Business Practice Location Address
First Line	:	50439 INDEPENDENCE ST
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-6735
Country	:	US
Telephone Number	:	734-879-1068
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. KENNETH J GRIMM
Credential	:	MD
Telephone Number	:	734-645-9228

Provider Enumeration Date	:	01/06/2012
Last Update Date	:	07/05/2012

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