Provider Demographics
NPI:1548347206
Name:GROUP MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:GROUP MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OBIOMA
Authorized Official - Middle Name:S
Authorized Official - Last Name:AGOMUOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-893-8314
Mailing Address - Street 1:27900 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4957
Mailing Address - Country:US
Mailing Address - Phone:313-893-8314
Mailing Address - Fax:313-893-7532
Practice Address - Street 1:3120 CARPENTER ST
Practice Address - Street 2:STE 111
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-9802
Practice Address - Country:US
Practice Address - Phone:313-893-8314
Practice Address - Fax:313-893-7532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063912207QA0000X, 208D00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301063912OtherMICHIGAN LIC
MI4149140 10Medicaid
MI4301063912OtherMICHIGAN LIC