Healthcare Provider Details

I. General information

NPI: 1457782450
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF MICHIGAN - AMBULATORY CTR FOR VEIN TRTMT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19900 HAGGERTY RD SUITE 105
LIVONIA MI
48152-1054
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-432-7811
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name: DAVID A SPAHLINGER
Title or Position: EXEC MEDICAL DIRECTOR FACULTY GRP
Credential: MD
Phone: 734-936-3568