Healthcare Provider Details

I. General information

NPI: 1548704257
Provider Name (Legal Business Name): DEGARA GARDEN CITY APP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 INKSTER RD
GARDEN CITY MI
48135-4001
US

IV. Provider business mailing address

PO BOX 4458 DEPT # 212
HOUSTON TX
77210-4458
US

V. Phone/Fax

Practice location:
  • Phone: 734-458-3300
  • Fax: 904-559-4370
Mailing address:
  • Phone: 866-434-3164
  • Fax: 904-559-4370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES SOMERBY
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-346-3088