Healthcare Provider Details

I. General information

NPI: 1548325186
Provider Name (Legal Business Name): RUDY J VERVAEKE MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24211 LITTLE MACK AVE
SAINT CLAIR SHORES MI
48080-1151
US

IV. Provider business mailing address

24211 LITTLE MACK AVE
SAINT CLAIR SHORES MI
48080-1151
US

V. Phone/Fax

Practice location:
  • Phone: 586-775-7400
  • Fax: 586-775-0091
Mailing address:
  • Phone: 586-775-7400
  • Fax: 586-775-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4301044898
License Number StateMI

VIII. Authorized Official

Name: DR. RUDY JEROME VERVAEKE
Title or Position: CEO
Credential: M.D.
Phone: 586-775-7400