Healthcare Provider Details

I. General information

NPI: 1891131165
Provider Name (Legal Business Name): CHRISTOPHER RYAN HETRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44405 WOODWARD AVE
PONTIAC MI
48341-5023
US

IV. Provider business mailing address

2006 HOGBACK RD STE 5A
ANN ARBOR MI
48105-9750
US

V. Phone/Fax

Practice location:
  • Phone: 248-585-3023
  • Fax: 412-359-3483
Mailing address:
  • Phone: 734-263-2400
  • Fax: 734-773-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD461206
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301506742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: