MEDICARE: JOHN CHARLES STABB PAC

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	363A00000X	Physician Assistant	5601001209	MI

General Provider Information

NPI Number	:	1639301898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN CHARLES STABB PAC

Provider Business Mailing Address
First Line	:	4771 MICHIGAN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48210-3247
Country	:	US
Telephone Number	:	313-897-2600
Fax Number	:	313-897-2424

Provider Business Practice Location Address
First Line	:	4771 MICHIGAN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48210-3247
Country	:	US
Telephone Number	:	313-897-2600
Fax Number	:	313-897-2424

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

Provider Enumeration Date	:	08/20/2009
Last Update Date	:	08/20/2009

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Directions to “ JOHN CHARLES STABB PAC” Practice Location

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