Healthcare Provider Details

I. General information

NPI: 1871949925
Provider Name (Legal Business Name): PHILIP STANLEY VENDITTELLI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2016
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18303 E 10 MILE RD STE 100
ROSEVILLE MI
48066-4989
US

IV. Provider business mailing address

22101 MOROSS RD FL 2
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 586-776-8877
  • Fax: 586-776-3092
Mailing address:
  • Phone: 313-343-4612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101022293
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number51024546
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number5315204612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: