Healthcare Provider Details

I. General information

NPI: 1073573366
Provider Name (Legal Business Name): ALICE DEA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST
DETROIT MI
48201-2018
US

IV. Provider business mailing address

750 BERKSHIRE RD
GROSSE POINTE PARK MI
48230-1818
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-8040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301048108
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301048108
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: