Healthcare Provider Details

I. General information

NPI: 1043258759
Provider Name (Legal Business Name): TERA MELANNE GOLDMAKHER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33155 ANNAPOLIS ST EMERGENCY DEPT
WAYNE MI
48184-2405
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-4042
  • Fax: 734-467-5500
Mailing address:
  • Phone: 734-805-0488
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35769
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC53679
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301078436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: