Healthcare Provider Details

I. General information

NPI: 1407812464
Provider Name (Legal Business Name): DANIEL ROBERT FERMAGLICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N ELM AVE
JACKSON MI
49202-3571
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-6760
  • Fax: 517-788-3029
Mailing address:
  • Phone: 517-841-6913
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301086739
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: