Healthcare Provider Details

I. General information

NPI: 1861028821
Provider Name (Legal Business Name): VINCENT HANNOSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IHA WATERFORD PRIMARY 4400 HIGHLAND RD
WATERFORD MI
48328
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 248-618-6000
  • Fax: 248-618-6951
Mailing address:
  • Phone: 734-853-5660
  • Fax: 734-853-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301508677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: