Healthcare Provider Details

I. General information

NPI: 1740205111
Provider Name (Legal Business Name): MICHAEL DEBACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 E M-36
PINCKNEY MI
48169
US

IV. Provider business mailing address

PO BOX 948, LOBBY J 24 FRANK LLOYD WRIGHT
ANN ARBOR MI
48106-0446
US

V. Phone/Fax

Practice location:
  • Phone: 734-878-1000
  • Fax: 734-878-1001
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301061331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: