MEDICARE: MR. ACE JAMES TACDERAS NP

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	363LA2200X	Adult Health Nurse Practitioner	4704234922	MI

General Provider Information

NPI Number	:	1447544176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ACE JAMES TACDERAS NP

Provider Business Mailing Address
First Line	:	17700 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1154
Country	:	US
Telephone Number	:	586-868-9120
Fax Number	:	586-868-9136

Provider Business Practice Location Address
First Line	:	17700 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1154
Country	:	US
Telephone Number	:	586-868-9120
Fax Number	:	586-868-9136

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

Provider Enumeration Date	:	05/28/2011
Last Update Date	:	11/12/2015

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