Healthcare Provider Details

I. General information

NPI: 1205065547
Provider Name (Legal Business Name): MARY ANN RAMBUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANN ELLIOTT PA-C

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax: 313-576-1112
Mailing address:
  • Phone: 313-576-1000
  • Fax: 313-576-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number840748
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number840748
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: