Healthcare Provider Details

I. General information

NPI: 1538616008
Provider Name (Legal Business Name): A. PETER EVANGELISTA, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 FARMINGTON RD
LIVONIA MI
48150-5704
US

IV. Provider business mailing address

7071 ORCHARD LAKE RD SUITE 333
WEST BLOOMFIELD MI
48322-3613
US

V. Phone/Fax

Practice location:
  • Phone: 734-427-9440
  • Fax: 734-427-1071
Mailing address:
  • Phone: 248-626-0470
  • Fax: 248-626-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301108922
License Number StateMI

VIII. Authorized Official

Name: DR. AUGUSTUS PETER EVANGELISTA
Title or Position: CEO
Credential: M
Phone: 248-626-0470