MEDICARE: GREGORY PAUL DERDERIAN D.O.

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	2086S0129X	Vascular Surgery Physician	5101007182	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457355737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY PAUL DERDERIAN D.O.

Provider Business Mailing Address
First Line	:	538 N OLD WOODWARD AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-5375
Country	:	US
Telephone Number	:	248-594-3091
Fax Number	:	248-594-3068

Provider Business Practice Location Address
First Line	:	538 N OLD WOODWARD AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-5375
Country	:	US
Telephone Number	:	248-594-3091
Fax Number	:	248-594-3068

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

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	09/18/2012

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