Healthcare Provider Details

I. General information

NPI: 1417426214
Provider Name (Legal Business Name): MATTHEW D BACH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD # K12
DETROIT MI
48202-2689
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2181
  • Fax:
Mailing address:
  • Phone: 313-916-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: