MEDICARE: CAROLYN MARIE DEMETRIOU RN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704172631	MI

General Provider Information

NPI Number	:	1033732672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN MARIE DEMETRIOU RN

Provider Business Mailing Address
First Line	:	261 FRANKLIN ST
Second Line	:
City	:	HOLLY
State	:	MI
Zip	:	48442-8576
Country	:	US
Telephone Number	:	734-223-9990
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 TOWNE SQ
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-3769
Country	:	US
Telephone Number	:	313-208-7376
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2020
Last Update Date	:	05/18/2020

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