Healthcare Provider Details

I. General information

NPI: 1417025941
Provider Name (Legal Business Name): JOHN D. BUCKLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

HENRY FORD HOSPITAL 2799 W GRAND BLVD
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2733
  • Fax: 313-916-9102
Mailing address:
  • Phone: 313-916-2433
  • Fax: 313-916-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01038587A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01038587A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01038587A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301070640
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: