Healthcare Provider Details

I. General information

NPI: 1457745564
Provider Name (Legal Business Name): MICHAEL LUCAS PERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST UHC 9C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4501 WOODWARD AVE APT 523
DETROIT MI
48201-1898
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5009
  • Fax:
Mailing address:
  • Phone: 785-817-1712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301502207
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: