Healthcare Provider Details

I. General information

NPI: 1912392275
Provider Name (Legal Business Name): ANTHONY IACCO MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD SUITE 204
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

3535 W 13 MILE RD SUITE 204
ROYAL OAK MI
48073-6770
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-9095
  • Fax: 248-551-9080
Mailing address:
  • Phone: 248-551-9095
  • Fax: 248-551-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301092602
License Number StateMI

VIII. Authorized Official

Name: ANTHONY IACCO
Title or Position: OWNER
Credential: MD
Phone: 734-657-2409