Healthcare Provider Details

I. General information

NPI: 1558589671
Provider Name (Legal Business Name): PATRICK HEREK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORD PL
DETROIT MI
48202-3450
US

IV. Provider business mailing address

605 HORTON ST
NORTHVILLE MI
48167-1209
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-6677
  • Fax:
Mailing address:
  • Phone: 734-635-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301097232
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: