Healthcare Provider Details

I. General information

NPI: 1629167267
Provider Name (Legal Business Name): SEBASTIAN J. LOPICCOLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

13186 PARTRIDGE RUN
SHELBY TOWNSHIP MI
48315-6943
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-6864
  • Fax:
Mailing address:
  • Phone: 586-739-8984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704164373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: