=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952504987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIA LIVIERATOS MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 05/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5799 S MAIN ST #1472
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48347-9907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-620-1275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5799 S. MAIN ST. #1472
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48347-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-620-1275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SINGLE MEMBER
-----------------------------------------------------
Name | DR. MARIA LIVIERATOS
-----------------------------------------------------
Credential | M.D.,
-----------------------------------------------------
Telephone | 248-620-1275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301064240
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------