Healthcare Provider Details

I. General information

NPI: 1497279509
Provider Name (Legal Business Name): MARY THERESE URBANEK M.S. PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 KAYSER AVE
ROYAL OAK MI
48067-2865
US

IV. Provider business mailing address

126 KAYSER AVE
ROYAL OAK MI
48067-2865
US

V. Phone/Fax

Practice location:
  • Phone: 248-399-3923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002717
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: