Provider Demographics
NPI:1538358742
Name:MARSHALL MEDLEY, D.O., P.C.
Entity type:Organization
Organization Name:MARSHALL MEDLEY, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:MEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-421-1000
Mailing Address - Street 1:35600 CENTRAL CITY PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2046
Mailing Address - Country:US
Mailing Address - Phone:734-421-1000
Mailing Address - Fax:734-421-1001
Practice Address - Street 1:35600 CENTRAL CITY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2046
Practice Address - Country:US
Practice Address - Phone:734-421-1000
Practice Address - Fax:734-421-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010137692086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0007367710OtherAETNA
MI4774341Medicaid
MI5821256OtherBCBS
MIU92085OtherPHCS
MIP36227-FOtherBCN
MI17178OtherMCARE
MI12192OtherCAPE HEALTH PLAN
MI450851OtherGREAT LAKES
MI17178OtherMCARE
MI5821256OtherBCBS