Provider Demographics
NPI:1366798373
Name:A3 MEDICAL
Entity type:Organization
Organization Name:A3 MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NOT APPLICABLE
Authorized Official - Prefix:
Authorized Official - First Name:SUPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:SOOKKASIKON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-885-8211
Mailing Address - Street 1:4050 W MAPLE ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301
Mailing Address - Country:US
Mailing Address - Phone:248-885-8211
Mailing Address - Fax:248-855-8357
Practice Address - Street 1:4050 W MAPLE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48301
Practice Address - Country:US
Practice Address - Phone:248-885-8211
Practice Address - Fax:248-855-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083253207Q00000X
261QU0200X
MI4301080609207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty