Healthcare Provider Details

I. General information

NPI: 1396122883
Provider Name (Legal Business Name): JAMES MICHAEL VANDAELE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17877 W 14 MILE RD
BEVERLY HILLS MI
48025
US

IV. Provider business mailing address

17877 W 14 MILE RD
BEVERLY HILLS MI
48025-3127
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-3920
  • Fax: 248-644-2569
Mailing address:
  • Phone: 248-644-3920
  • Fax: 248-644-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number018604
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601008593
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008593
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: