Healthcare Provider Details

I. General information

NPI: 1174103634
Provider Name (Legal Business Name): DALCOMA PHARMACOPOEIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43475 DALCOMA DR STE 150
CLINTON TOWNSHIP MI
48038-3594
US

IV. Provider business mailing address

43475 DALCOMA DR STE 150
CLINTON TOWNSHIP MI
48038-3594
US

V. Phone/Fax

Practice location:
  • Phone: 586-421-7440
  • Fax: 248-281-9955
Mailing address:
  • Phone: 586-421-7440
  • Fax: 248-281-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK L GOLDBERGER
Title or Position: MANAGER
Credential: DO
Phone: 248-320-6101