Healthcare Provider Details

I. General information

NPI: 1932636149
Provider Name (Legal Business Name): TYLER SCOTT DETTRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W GREENLAWN AVE
LANSING MI
48910-2819
US

IV. Provider business mailing address

401 W GREENLAWN AVE
LANSING MI
48910-2819
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-6000
  • Fax:
Mailing address:
  • Phone: 517-975-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301501004
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: