MEDICARE: DTG II PLLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1457132201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DTG II PLLC

Provider Business Mailing Address
First Line	:	811 E KENT RD
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-9791
Country	:	US
Telephone Number	:	800-268-7713
Fax Number	:	415-704-3294

Provider Business Practice Location Address
First Line	:	1200 N ASHLAND AVE STE 500
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-8327
Country	:	US
Telephone Number	:	800-268-7713
Fax Number	:	415-704-3294

Authorized Official
Title or Position	:	SVP OF MANAGED CARE
Name	:	KANDY MORRIS
Credential	:
Telephone Number	:	877-795-2361

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	10/09/2023

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