Healthcare Provider Details

I. General information

NPI: 1023217437
Provider Name (Legal Business Name): CASSANDRA WORMACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 JOLLY RD STE. B
OKEMOS MI
48864-3983
US

IV. Provider business mailing address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-4085
  • Fax: 517-347-4170
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301072467
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301072467
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301072467
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: