MEDICARE: PRIMARY CARE HOME SERVICES, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163W00000X	Registered Nurse
2	363LP2300X	Primary Care Nurse Practitioner
3	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1871852533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE HOME SERVICES, INC

Provider Business Mailing Address
First Line	:	2990 W GRAND BLVD
Second Line	:	SUITE 307
City	:	DETROIT
State	:	MI
Zip	:	48202-3041
Country	:	US
Telephone Number	:	313-870-9260
Fax Number	:	313-870-9266

Provider Business Practice Location Address
First Line	:	2990 W GRAND BLVD
Second Line	:	SUITE 307
City	:	DETROIT
State	:	MI
Zip	:	48202-3041
Country	:	US
Telephone Number	:	313-870-9260
Fax Number	:	313-870-9266

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LAYNETTE GOUDY-EGGER
Credential	:	NURSE PRACTITIONER
Telephone Number	:	313-870-9260

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	05/15/2012

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