Healthcare Provider Details

I. General information

NPI: 1609077783
Provider Name (Legal Business Name): MICHIGAN VASCULAR ACCESS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21701 W 11 MILE RD
SOUTHFIELD MI
48076-3713
US

IV. Provider business mailing address

21701 W 11 MILE RD
SOUTHFIELD MI
48076-3713
US

V. Phone/Fax

Practice location:
  • Phone: 248-355-1100
  • Fax:
Mailing address:
  • Phone: 248-355-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMW051199
License Number StateMI

VIII. Authorized Official

Name: MARC WEBB
Title or Position: PRESIDENT
Credential: M D
Phone: 248-355-1100