Healthcare Provider Details

I. General information

NPI: 1790729366
Provider Name (Legal Business Name): RONALD GENE ZACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20276 MIDDLEBELT RD SUITE 2
LIVONIA MI
48152-2054
US

IV. Provider business mailing address

20276 MIDDLEBELT RD SUITE 2
LIVONIA MI
48152-2054
US

V. Phone/Fax

Practice location:
  • Phone: 248-476-4900
  • Fax: 248-476-5435
Mailing address:
  • Phone: 248-476-4900
  • Fax: 248-476-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberRZ033941
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: