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General NPI Number Information
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NPI Number | 1912392275
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Entity Type | Organization
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Legal Business Name | ANTHONY IACCO MD PLC
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Dates
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Enumeration Date | 04/03/2015
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Last Update Date | 04/03/2015
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Provider Practice Location Address
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Address Line | 3535 W 13 MILE RD SUITE 204
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City | ROYAL OAK
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State | MI
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Zip | 48073-6770
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Country | US
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Telephone | 248-551-9095
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Fax | 248-551-9080
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Provider Business Mailing Address
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Address Line | 3535 W 13 MILE RD SUITE 204
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City | ROYAL OAK
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State | MI
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Zip | 48073-6770
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Country | US
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Telephone | 248-551-9095
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Fax | 248-551-9080
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Authorized Official
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Title or Position | OWNER
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Name | ANTHONY IACCO
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Credential | MD
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Telephone | 734-657-2409
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4301092602
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License Number State | MI
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