Healthcare Provider Details

I. General information

NPI: 1326053083
Provider Name (Legal Business Name): ALI MARIA LUCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-3353
  • Fax:
Mailing address:
  • Phone: 248-325-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number4301097403
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: