Healthcare Provider Details

I. General information

NPI: 1265660062
Provider Name (Legal Business Name): JEREMY RYAN CIULLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 E 13 MILE RD STE 112
WARREN MI
48093
US

IV. Provider business mailing address

11012 E 13 MILE RD STE 112
WARREN MI
48093-2546
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5880
  • Fax: 586-573-2562
Mailing address:
  • Phone: 586-751-3380
  • Fax: 586-751-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number4301094831
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number4301094921
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: