Healthcare Provider Details

I. General information

NPI: 1255308615
Provider Name (Legal Business Name): TAMMY SAMUEL DUSEVIC DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13425 19 MILE RD STE 100
STERLING HTS MI
48313
US

IV. Provider business mailing address

13425 19 MILE RD STE 100
STERLING HTS MI
48313-1991
US

V. Phone/Fax

Practice location:
  • Phone: 586-843-3935
  • Fax: 586-843-3947
Mailing address:
  • Phone: 586-843-3935
  • Fax: 586-843-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101014333
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: