Provider Demographics
NPI:1548474315
Name:FREEDOM MEDICAL CLINIC PC
Entity type:Organization
Organization Name:FREEDOM MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-476-4724
Mailing Address - Street 1:20206 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1412
Mailing Address - Country:US
Mailing Address - Phone:248-476-4724
Mailing Address - Fax:
Practice Address - Street 1:20206 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1412
Practice Address - Country:US
Practice Address - Phone:248-476-4724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREEDOM MEDICAL CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-10
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH26335Medicare ID - Type Unspecified