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General NPI Number Information
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NPI Number | 1366798373
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Entity Type | Organization
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Legal Business Name | A3 MEDICAL
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Dates
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Enumeration Date | 07/27/2012
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Last Update Date | 10/14/2022
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Provider Practice Location Address
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Address Line | 4050 W MAPLE ROAD SUITE 101
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City | BLOOMFIELD
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State | MI
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Zip | 48301
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Country | US
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Telephone | 248-885-8211
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Fax | 248-855-8357
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Provider Business Mailing Address
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Address Line | 4050 W MAPLE ROAD SUITE 101
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City | BLOOMFIELD
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State | MI
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Zip | 48301
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Country | US
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Telephone | 248-885-8211
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Fax | 248-855-8357
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Authorized Official
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Title or Position | NOT APPLICABLE
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Name | SUPAK SOOKKASIKON
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Credential | MD
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Telephone | 248-885-8211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301083253
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301080609
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License Number State | MI
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