=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629240965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL J MUCCI M.D.P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2008
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15590 W 13 MILE RD SUITE A
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48025-5642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-283-1115
-----------------------------------------------------
Fax | 248-283-1119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15590 W 13 MILE RD SUITE A
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48025-5642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-283-1115
-----------------------------------------------------
Fax | 248-283-1119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | MRS. MICHELE A BARC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-283-1115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301067463
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------