=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952323016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE GEORGE ENGELMANN DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 07/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1990 UNION LAKE RD STE 100
-----------------------------------------------------
City | COMMERCE TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48382-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-303-4680
-----------------------------------------------------
Fax | 248-572-4995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 355
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48366-0355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-303-4680
-----------------------------------------------------
Fax | 248-572-4995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TE007018
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | TE007018
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------