Healthcare Provider Details

I. General information

NPI: 1417674912
Provider Name (Legal Business Name): ALEX J HERRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

V. Phone/Fax

Practice location:
  • Phone: 419-213-7368
  • Fax:
Mailing address:
  • Phone: 419-213-7368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4704319221
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: